What is the best course of action for a diabetic patient with an untreated ingrown toenail on their right great toe, who is experiencing pain and limping, but has no swelling or discoloration, and is unable to travel for treatment due to financial constraints?

Management of Untreated Ingrown Toenail in Diabetic Patient with Financial Barriers

This patient requires immediate in-office treatment of the ingrown toenail by you or another available provider, combined with pain management and close monitoring for infection, as delaying professional treatment in a diabetic patient significantly increases the risk of ulceration, infection, and amputation. 1

Immediate Action Required

Professional Treatment is Non-Negotiable

• Treating ingrown toenails in diabetic patients is a strong recommendation to prevent progression to foot ulcers and serious complications 1
• The International Working Group on the Diabetic Foot explicitly states that pre-ulcerative signs (including ingrown toenails) require immediate treatment by a foot care professional 1
• This patient's pain and limping indicate the ingrown nail is causing ongoing tissue trauma, which in diabetes can rapidly progress to ulceration even without visible swelling or discoloration 1

Treatment Options You Can Provide Now

Conservative in-office management:

• Remove the ingrown portion of the nail under local anesthesia 2, 3, 4
• This can be done in primary care with lidocaine injection and basic instruments 4
• Soak preparation with Epsom salt or betadine solution before the procedure 2
• Consider nail brace application if available - this is specifically studied in diabetic patients with 71% success rate (15/21 patients) without surgery 5

Pain management:

• Prescribe oral analgesics (acetaminophen or NSAIDs if not contraindicated) for short-term use 4
• Pain relief is typically immediate once the offending nail portion is removed 5, 4

Why Delay is Dangerous in This Patient

Diabetes-Specific Risks

• Even small foot problems like ingrown toenails can lead to infection and slow healing in diabetic patients 1
• The absence of swelling or discoloration does NOT mean the tissue is healthy - diabetic neuropathy can mask early signs of tissue damage 1
• His continued limping indicates ongoing mechanical trauma that is creating a pre-ulcerative condition 1
• One case report documents progression from ingrown toenail surgery to gangrene and amputation in a young patient, highlighting the serious potential complications 6

Current Clinical Status Indicates Progression

• Pain severe enough to limit walking is a red flag 1
• Limping creates abnormal pressure distribution on other parts of the foot, potentially causing additional problems 1
• The longer this persists, the higher the risk of skin breakdown and ulceration 1

Practical Implementation Given Financial Barriers

If You Can Treat In-Office

• Perform partial nail avulsion yourself - this is within primary care scope 4
• Use local anesthesia (lidocaine 1-2% without epinephrine) 4
• Remove only the ingrown lateral edge, not the entire nail 4
• Apply antibiotic ointment and simple dressing 4
• This avoids referral costs while providing definitive treatment 5, 4

If You Cannot Perform the Procedure

• Contact local podiatry offices to negotiate reduced fee or payment plan given diabetes risk 1
• Some facilities have charity care programs for diabetic foot problems 1
• Consider reaching out to hospital-based podiatry that may have sliding scale fees 1
• Document that patient is at high risk and treatment delay could result in hospitalization (which is far more costly) 1

Post-Treatment Care Instructions

Immediate Follow-Up Plan

• See patient in 48-72 hours to assess for infection 4
• Teach proper nail trimming technique (straight across, not curved) 1, 3
• Emphasize daily foot inspection for redness, swelling, drainage, or warmth 1
• Ensure properly fitting footwear that doesn't compress toes 1

Ongoing Diabetic Foot Care

• This patient needs integrated foot care every 1-3 months including professional nail care, footwear assessment, and education 1
• Schedule regular follow-ups for preventive foot care to avoid future problems 1
• Optimize diabetes control to improve healing capacity 7

Red Flags Requiring Emergency Care

Instruct patient to go to ER immediately if he develops:

• Fever or chills 1
• Spreading redness up the foot or leg 1
• Purulent drainage or foul odor 1
• Black or darkened tissue 1, 6
• Worsening pain despite treatment 1

Critical Pitfall to Avoid

Do not tell this patient to wait or continue conservative home care - he has already been limping with ongoing pain, indicating failed conservative management 1. The IWGDF guidelines are explicit that ingrown toenails in diabetic patients require professional treatment, not patient self-management 1. Waiting for him to "find money" or "be willing to travel" while he continues to limp is allowing a preventable complication to progress toward ulceration and potential amputation 1, 6.