What is the recommended treatment for an ingrown toenail?

Ingrown Toenail Treatment

For mild ingrown toenails, start with conservative management including twice-daily antiseptic soaks for 10-15 minutes followed immediately by mid- to high-potency topical corticosteroid ointment to the nail fold, combined with mechanical relief techniques such as cotton wisp insertion or gutter splinting; reserve surgical intervention (partial nail avulsion with phenolization) for moderate-to-severe cases, recurrent cases, or those failing 2-4 weeks of conservative therapy. 1, 2

Initial Assessment and Conservative Management

First-Line Conservative Approach

• Perform antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution) or 2% povidone-iodine solution 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily immediately after soaking to reduce local inflammation 1, 2
• This conservative approach is appropriate for mild cases without significant infection 2

Mechanical Relief Techniques

• Consider mechanical separation using cotton wisp or dental floss insertion under the ingrown lateral nail edge 2, 3
• Gutter splinting using a plastic tube with a lengthwise incision placed on the lateral nail edge provides immediate pain relief 2, 3
• Taping the lateral nail fold away from the nail plate is an alternative mechanical approach 2

Footwear and Nail Care Modifications

• Correct inappropriate footwear by wearing comfortable, well-fitting shoes with adequate toe box space to reduce pressure 1
• Trim toenails straight across (not too short and not rounded at corners) to prevent recurrence 1, 2
• Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1, 2

Antibiotic Considerations

When to Use Antibiotics

• Do not routinely prescribe antibiotics for mild ingrown toenails unless clear signs of infection are present 2
• Indications for antibiotics include: purulent drainage requiring culture or localized cellulitis with significant erythema extending beyond the nail fold 2
• Coverage should target Staphylococcus aureus and gram-positive organisms 2
• For recurrent, severe, or treatment-refractory cases, consider doxycycline 100 mg twice daily with follow-up after one month 2

Surgical Management

Indications for Surgical Intervention

• Escalate to surgical consultation if:
  • Persistent pain or drainage continues beyond 2-4 weeks despite appropriate conservative therapy 2
  • Granulation tissue develops 2
  • Moderate to severe cases at initial presentation 3

Surgical Approach

• Partial nail avulsion combined with phenolization is more effective at preventing symptomatic recurrence compared to surgical excision without phenolization, though it carries a slightly increased risk of postoperative infection 4
• Partial nail avulsion followed by either phenolization or direct surgical excision of the nail matrix are equally effective treatment options 4
• Various other surgical techniques exist including the Winograd technique, Vandenbos procedure, radiofrequency ablation, and carbon dioxide laser ablation, with choice depending on severity and recurrence patterns 5

Post-Procedure Care

• Continue antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily to aid healing 1
• Apply mid- to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 1
• Avoid trauma to the affected digit and wear protective gloves during activities involving water exposure or chemicals 1

Special Populations

Diabetic Patients

• Diabetic patients require more aggressive monitoring and prompt treatment by trained healthcare professionals, as ingrown toenails can progress to foot ulceration with significant morbidity 2
• Integrated foot care should be provided every 1-3 months for diabetic patients 2
• For diabetic patients at risk of foot ulceration, appropriate treatment should be provided by a trained healthcare professional to prevent complications 1

Monitoring and Follow-Up

• Reassess the patient after 2 weeks of conservative management 2
• Escalate care if no improvement is seen with conservative measures within the 2-4 week timeframe 2

Common Pitfalls to Avoid

• Avoid rounding the corners when trimming toenails, as this increases recurrence risk 1, 2
• Do not prescribe antibiotics routinely without clear signs of infection, as this contributes to unnecessary antibiotic use 2
• Do not delay surgical referral in diabetic patients or those with persistent symptoms beyond 2-4 weeks of conservative therapy 2