What is the best treatment approach for a patient presenting with an ingrown toenail?

Management of Ingrown Toenails

For mild to moderate ingrown toenails, start with conservative management including antiseptic soaks twice daily and mid- to high-potency topical corticosteroids, reserving surgical intervention for severe cases or those failing 2-4 weeks of conservative therapy. 1, 2

Initial Assessment

Evaluate the severity by examining for:

• Redness, edema, discharge, and granulation tissue to grade the condition 1
• Purulent drainage or cellulitis indicating infection requiring antibiotic coverage for Staphylococcus aureus 3, 2
• Risk stratification in diabetic patients, as ingrown toenails can progress to foot ulceration with significant morbidity 3, 2

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

Antiseptic Soaks and Topical Therapy

• Perform antiseptic soaks for 10-15 minutes twice daily using either dilute vinegar (50:50 dilution) or 2% povidone-iodine solution 3, 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily immediately after soaking to reduce inflammation 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 1

Mechanical Relief Techniques

• Consider gutter splinting by placing a plastic tube with a lengthwise incision on the lateral nail edge to provide immediate pain relief 1, 2
• Alternative mechanical methods include placing cotton wisps or dental floss under the ingrown lateral nail edge, or taping the lateral nail fold away from the nail plate 2, 4

Antibiotic Therapy

Do not routinely prescribe antibiotics for mild ingrown toenails unless clear signs of infection are present 2

When antibiotics are indicated:

• Start with cephalexin as first-line therapy for coverage of Staphylococcus aureus and gram-positive organisms 1, 2
• Switch to sulfamethoxazole-trimethoprim (Bactrim) if initial treatment fails, for broader coverage including MRSA 1
• For recurrent or treatment-refractory cases, consider doxycycline 100 mg twice daily 2
• Be aware that secondary bacterial or mycological superinfections occur in up to 25% of cases 1

Management of Complications

Pyogenic Granuloma

• Consider scoop shave removal with hyfrecation or silver nitrate application for granulation tissue formation 1
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 1
• Intralesional triamcinolone acetonide may be considered for severe or refractory cases 1

Underlying Onychomycosis

• Treat with appropriate antifungal therapy if cultures are positive, as fungal infection contributes to recurrence 3

Surgical Intervention

Consider partial nail avulsion if pain is intolerable despite conservative management, or if no improvement after 2-4 weeks of appropriate conservative therapy 1, 2

Surgical indications include:

• Persistent pain or drainage beyond 2-4 weeks despite conservative treatment 2
• Development of granulation tissue 2
• Presence of painful hematoma or subungual abscess 1
• Recurrent episodes despite proper preventive measures 3, 5

Prevention of Recurrence

Nail Care Technique

• Cut toenails straight across, never rounded at corners, and avoid cutting too short 3, 2
• Never use nails as tools or manipulate cuticles 2

Footwear and Hygiene

• Wear comfortable, well-fitting shoes and cotton socks 1, 2
• Avoid repeated friction, trauma, and excessive pressure 1
• Daily foot washing with careful drying between toes 3
• Apply topical emollients daily to cuticles and periungual tissues 3, 2
• Use protective gloves when working with water or chemicals 1, 2

Special Considerations for Diabetic Patients

Diabetic patients require more aggressive monitoring and prompt treatment by trained healthcare professionals 2

• Provide integrated foot care every 1-3 months for moderate-to-high risk patients (IWGDF risk 2-3) to prevent progression to foot ulceration 3, 2
• Consider extra-depth shoes or custom-made footwear if foot deformities are present 3
• Rule out infection before any procedure by checking for purulent drainage, significant erythema, or cellulitis 3

Follow-Up and Monitoring

• Reassess after 2 weeks of conservative management 2
• Escalate to surgical consultation if symptoms persist beyond 2-4 weeks despite appropriate conservative therapy 2
• For diabetic patients, maintain regular surveillance according to risk stratification 3

Common Pitfalls to Avoid

Do not delay treatment in diabetic patients, as ingrown toenails can rapidly progress to serious foot complications 3, 2. Avoid prescribing antibiotics without clear signs of infection, as this contributes to antimicrobial resistance without improving outcomes 2, 5. Do not perform surgical procedures without first ruling out infection in diabetic patients, as this increases risk of complications 3.