What is the best course of treatment for a patient with an ingrown toenail, considering potential complications and underlying health conditions?

Management of Ingrown Toenail

For uncomplicated ingrown toenails, begin with conservative measures including warm water soaks, proper nail trimming technique (straight across), cotton/dental floss placement under the nail edge, and gutter splinting; reserve surgical intervention with partial nail avulsion and phenol matricectomy for moderate-to-severe cases or when conservative treatment fails. 1, 2

Initial Assessment and Risk Stratification

Before initiating treatment, assess for critical underlying conditions that alter management:

• In diabetic patients: Ingrown toenails require immediate evaluation by an appropriately trained healthcare professional to prevent ulceration 3
• Check for infection: Look for at least two signs of inflammation (redness, warmth, induration, pain/tenderness) or purulent secretions 3
• Assess vascular status: In diabetic or high-risk patients, evaluate for peripheral artery disease before any intervention 3, 4

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

For early-stage ingrown toenails without severe infection or complications:

• Warm water soaks: Soak the affected foot in warm, soapy water to soften tissue and reduce inflammation 1, 2
• Proper nail trimming: Cut toenails straight across, never rounded, to prevent recurrence 3
• Cotton wisp or dental floss technique: Place small amounts under the ingrown nail edge to lift it away from the lateral nail fold 1, 2
• Gutter splinting: Apply a gutter splint to separate the nail plate from the lateral fold, providing immediate pain relief 2
• Topical steroids: Apply mid-to-high potency topical steroid ointment to reduce inflammation and edema 2
• Footwear modification: Ensure properly fitted shoes that don't compress the toes 3, 5

Important caveat: Conservative measures work best for stage 1 disease (mild inflammation without drainage or infection) 6. If symptoms persist beyond 2-4 weeks of conservative treatment, surgical intervention should be considered 2.

Surgical Management (For Moderate-to-Severe or Recurrent Cases)

When conservative treatment fails or the patient presents with stage 2-3 disease (drainage, infection, or lateral wall hypertrophy):

The gold standard surgical approach is partial nail avulsion combined with chemical matricectomy using phenol 1, 2:

• Partial nail avulsion: Remove only the lateral edge of the nail plate that is ingrown 1, 2
• Phenol matricectomy: Apply phenol to the exposed nail matrix to prevent regrowth of the problematic nail edge 1
• Superior efficacy: This combination is more effective at preventing symptomatic recurrence compared to surgical excision without phenolization 1
• Slight infection risk: There is a marginally increased risk of postoperative infection compared to surgery alone, but the recurrence prevention benefit outweighs this risk 1

Alternative surgical techniques include:

• Electrocautery or radiofrequency ablation of the nail matrix 1, 6
• Carbon dioxide laser ablation 1
• Complete nail excision (reserved for severe, recalcitrant cases) 7

Infection Management

If infection is present (purulent drainage, significant erythema, warmth):

• Obtain cultures: Culture any purulent material before starting antibiotics 8
• Oral antibiotics: Initiate coverage against Staphylococcus aureus and gram-positive organisms 8
  • Options include: first-generation cephalosporins, amoxicillin-clavulanate, clindamycin, or doxycycline 8
• Debridement: Remove necrotic tissue and surrounding callus 3
• Reassess in 2 weeks: If no improvement, consider surgical intervention or referral 8

Critical pitfall: Prophylactic antibiotics are NOT indicated for uncomplicated ingrown toenails without signs of infection 8. Oral antibiotics before or after phenolization do not improve outcomes in non-infected cases 1.

Special Considerations for Diabetic Patients

Diabetic patients require heightened vigilance and modified approach:

• Avoid self-care: Patients should not attempt self-treatment of ingrown nails 3
• Professional evaluation: All ingrown toenails in diabetics warrant assessment by a foot care specialist 3
• Consider alternative procedures: For diabetic patients with hammertoe and nail changes, digital flexor tendon tenotomy may be preferred over nail removal 3, 4
• Urgent referral: Any diabetic patient with an ingrown nail plus signs of infection, swelling, or erythema requires urgent specialist referral 3

Prevention Strategies

To prevent recurrence after treatment:

• Daily nail inspection: Especially in high-risk patients 3
• Proper trimming technique: Always cut straight across, never rounded 3
• Moisturizers: Apply daily to periungual folds and nail plate 3
• Appropriate footwear: Well-fitted shoes that don't compress toes 3, 5
• Manage hyperhidrosis: Control excessive foot sweating which contributes to ingrown nails 5, 2

Common pitfall to avoid: Complete nail avulsion should NOT be performed routinely, as it has disappointing results and higher recurrence rates compared to partial avulsion with matricectomy 4, 1.