What are the management options for ingrown toenails?

Management of Ingrown Toenails

For mild to moderate ingrown toenails, initiate conservative management with daily antiseptic soaks and topical corticosteroids, reserving partial nail avulsion with phenolization for severe, infected, or treatment-refractory cases. 1, 2

Initial Assessment

Evaluate severity based on clinical parameters:

• Redness, edema, discharge, and presence of granulation tissue 1
• Check for pus or abscess formation requiring drainage 1
• Assess for secondary bacterial or mycological superinfection (present in up to 25% of cases) 3, 1

Conservative Management (First-Line for Mild-Moderate Cases)

Antiseptic Soaking Protocol

• Perform warm antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 1, 2
• Apply topical 2% povidone-iodine directly to the affected area twice daily 3, 1

Anti-Inflammatory Treatment

• Apply mid to high-potency topical corticosteroid ointment to nail folds twice daily immediately after soaking 1, 2
• The ointment vehicle is preferred over cream for better penetration in the periungual area 2

Mechanical Relief Options

• Gutter splinting: Place a plastic tube with lengthwise incision on the lateral nail edge to provide immediate pain relief 1, 2
• Cotton wisp or dental floss insertion under the ingrown nail edge to separate it from underlying tissue 2, 4
• Taping the lateral nail fold away from the nail plate 4

Antimicrobial Therapy for Infected Cases

When to Initiate Antibiotics

• If pus is present, obtain cultures and start antibiotics targeting Staphylococcus aureus and gram-positive organisms 2
• Both gram-positive and gram-negative organisms have been implicated in superinfections 3

Antibiotic Selection Algorithm

• First-line: Cephalexin for uncomplicated infections 1
• If initial treatment fails: Switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1
• For recurrent, severe, or treatment-refractory cases after 2-4 weeks: Consider doxycycline 100 mg twice daily with follow-up after one month 2

Management of Granulation Tissue

If pyogenic granuloma or excessive granulation tissue develops:

• Scoop shave removal with hyfrecation or silver nitrate chemical cauterization 1, 2
• Consider topical timolol 0.5% gel twice daily under occlusion as adjunctive therapy 1, 2
• For treatment-refractory cases: Intralesional triamcinolone acetonide injection 1, 2

Surgical Intervention

Indications for Surgery

• Intolerable pain despite conservative management 1
• Persistent pain or drainage beyond 2-4 weeks 2
• Severe cases with significant structural changes 5
• Recurrent ingrown toenails after failed conservative treatment 6, 4

Surgical Approach

• Partial nail avulsion combined with phenolization is the most effective surgical treatment 6, 4
• This approach is more effective at preventing symptomatic recurrence compared to surgical excision without phenolization, though it carries a slightly increased risk of postoperative infection 6
• Partial nail avulsion and direct surgical excision of the nail matrix are equally effective alternatives 6
• Note: Oral antibiotics before or after phenolization do not improve outcomes 6

Prevention of Recurrence

Nail Care Education

• Cut toenails straight across, not too short 3, 1, 2
• Avoid cutting cuticles or manipulating nail folds 2
• Daily application of topical emollients to cuticles and periungual tissues 3, 2

Footwear and Trauma Prevention

• Wear comfortable well-fitting shoes and cotton socks 3, 2
• Avoid repeated friction, trauma, and excessive pressure 3, 1
• Wear protective gloves during activities involving water or chemicals 1, 2

Hygiene Measures

• Maintain good hand and foot hygiene 2
• Manage hyperhidrosis if present 4
• Treat any concurrent onychomycosis 4

Follow-Up Protocol

• Reassess after 2 weeks of conservative treatment 3, 2
• If no improvement after 2 weeks, escalate to more aggressive interventions 3, 5
• Monitor post-procedure wound healing at 2 weeks for surgical cases 2
• Watch for signs of infection: increased pain, redness, swelling, or purulent drainage 2

Common Pitfalls to Avoid

• Do not stop topical steroids abruptly if infection develops—obtain cultures first, initiate appropriate antibiotics, then resume steroid therapy once infection is controlled 2
• Avoid cutting nails too short or in a curved fashion, as this is a major contributory factor 3, 4
• Do not use oral antibiotics routinely with phenolization, as they do not improve outcomes 6