What are the treatment options for a patient with an ingrown toenail, considering potential complications in patients with a history of diabetes or poor circulation?

Ingrown Toenail Management

In diabetic patients or those with poor circulation, ingrown toenails should be treated by a trained healthcare professional with conservative nail care as first-line therapy, reserving surgical intervention only for severe or recurrent cases after careful vascular assessment. 1

Risk Stratification is Critical

Before any treatment, you must assess the patient's risk category:

• Check for diabetes, peripheral neuropathy, peripheral arterial disease, and foot deformities – these factors dramatically alter your treatment approach and healing potential 1
• Evaluate for signs of infection (erythema, pain, swelling, purulence) which require urgent intervention 1
• Assess vascular status before any surgical intervention – poor circulation impairs healing and increases infection risk 1

Treatment Algorithm

For Uninfected Ingrown Toenails

Start with professional conservative care:

• Professional nail trimming by a trained healthcare provider is the recommended first-line approach, including removal of the ingrown nail portion, excess callus debridement, and careful nail border management 1, 2
• Conservative techniques provide immediate relief without surgery: nail bracing, orthotic interventions, and properly fitting footwear 1
• Cotton wisps or dental floss placement under the ingrown edge, gutter splinting, or cotton nail casts with cyanoacrylate adhesive can be effective for mild to moderate cases 3, 4

For Infected Ingrown Toenails

• Obtain cultures before starting antibiotics and consider broader spectrum coverage with longer duration for moderate infections 1
• Never delay treatment in diabetic patients – these can rapidly progress to serious limb-threatening infections 1

When Conservative Treatment Fails

Surgical intervention becomes necessary for recurrent or severe cases:

• Partial nail avulsion with phenolization is more effective than surgical excision alone at preventing recurrence, though it carries slightly higher infection risk 3
• Digital flexor tenotomy may be considered for hammertoes with nail changes or pre-ulcerative lesions when conservative treatment fails 2
• Complete nail excision is reserved for the most severe, recurrent cases 3, 5

Special Considerations for High-Risk Patients

Diabetic Patients Require Heightened Vigilance

• Ingrown toenails are pre-ulcerative lesions in diabetics requiring immediate professional treatment to prevent ulceration 6
• Integrated foot care is mandatory: professional treatment, appropriate footwear, and structured self-care education 2, 1
• Follow-up frequency depends on risk: every 1-3 months for high-risk patients (IWGDF risk 3), every 3-6 months for moderate-risk patients (IWGDF risk 2) 2, 1

Critical Pitfalls to Avoid

• Never allow self-treatment in patients with neuropathy – they cannot feel complications developing 1
• Check for coexisting fungal infections which commonly accompany ingrown nails in diabetic patients and require concurrent treatment 1, 2
• Avoid barefoot walking and ensure appropriate footwear that accommodates foot shape 2, 1

Prevention and Patient Education

Proper nail care technique is essential:

• Trim nails straight across, not too short – this is the primary preventive measure 1
• Daily foot inspection with prompt medical attention for any problems 1
• Appropriate footwear that fits properly and accommodates foot shape 2

Outcomes and Evidence Quality

Conservative treatment succeeds in 96% of mild cases (stages I-II) but fails in up to 62% of advanced cases (stage III), necessitating surgical intervention 7. Partial nail avulsion with phenolization demonstrates superior long-term outcomes compared to excision alone, with lower recurrence rates despite marginally higher infection risk 3.