Management of Ingrown Toenail
For a patient with an ingrown toenail, immediate professional treatment by a trained foot care specialist is mandatory if the patient has diabetes, while non-diabetic patients can be managed with conservative measures initially, escalating to partial nail avulsion with phenol matricectomy for moderate-to-severe or recurrent cases. 1, 2, 3
Critical First Step: Assess for Diabetes
If the patient has diabetes, this is a medical urgency requiring immediate referral to a foot care specialist – ingrown toenails are explicitly classified as pre-ulcerative lesions that demand professional treatment to prevent progression to foot ulcers, infection, and amputation. 1, 2, 4
Even without visible infection, swelling, or discoloration, an ingrown nail in a diabetic patient represents ongoing tissue trauma that can rapidly deteriorate due to neuropathy masking early warning signs and impaired healing capacity. 2, 4
Never allow diabetic patients to self-treat or delay care – the International Working Group on the Diabetic Foot gives a strong recommendation (high certainty evidence) to provide appropriate treatment for ingrown toenails in at-risk diabetic patients. 1
For Diabetic Patients: Specific Management Protocol
Immediate Actions
Refer urgently to podiatry or trained foot care professional for proper nail trimming, removal of the ingrown portion, and debridement of the nail border. 2, 4
Assess for infection signs (erythema, warmth, purulent drainage, fever) – if present, obtain cultures and start empiric antibiotics while awaiting specialist evaluation. 4
Evaluate peripheral neuropathy status (loss of protective sensation using 10-g monofilament), peripheral artery disease (check pedal pulses, consider ankle-brachial index if pulses absent), and presence of foot deformities. 1, 4
Risk Stratification and Follow-up
Use the IWGDF risk stratification system to determine ongoing surveillance frequency: patients with ingrown nails typically fall into risk category 2-3, requiring foot examinations every 1-6 months. 1, 4
Schedule integrated foot care including professional nail trimming, footwear assessment, and structured patient education on proper nail care technique (trim straight across, never curved). 1, 4
Patient Education for Diabetics
Instruct on daily foot inspection using mirrors or palpation if vision impaired, immediate reporting of any redness/swelling/drainage, and avoidance of barefoot walking or tight footwear. 1, 4
Teach proper nail trimming (straight across, not too short) and emphasize never attempting self-treatment of ingrown nails. 1, 4
Provide emergency warning signs: fever, spreading redness, purulent drainage, foul odor, black tissue, or worsening pain require immediate ER evaluation. 2
For Non-Diabetic Patients: Staged Treatment Approach
Stage 1 (Mild): Conservative Management
Initial treatment consists of warm water soaks (15 minutes twice daily), mid-to-high potency topical corticosteroid ointment to the nail fold, and placement of cotton wisps or dental floss under the ingrown nail edge to separate it from the lateral fold. 1, 3, 5
Gutter splinting (placing a flexible plastic tube with lengthwise incision over the lateral nail edge) provides immediate pain relief and is highly effective for mild cases. 1, 5
Correct improper footwear (shoes too tight or narrow) and address hyperhidrosis if present, as these are major contributing factors. 3, 6, 5
Stage 2 (Moderate): Infection Present
Characterized by worsening pain, drainage, and localized infection – can attempt conservative management as above plus oral antibiotics, but surgical intervention often needed. 6, 5
If no improvement within 1-2 weeks of conservative treatment, proceed to surgical management. 6, 5
Stage 3 (Severe): Lateral Wall Hypertrophy and Granulation Tissue
Definitive treatment is partial nail avulsion of the lateral nail edge combined with chemical matricectomy using phenol – this combination is more effective than nail avulsion alone at preventing recurrence (though with slightly higher infection risk). 3, 6, 5
The procedure involves: removing the lateral 3-4mm of nail plate, applying 88% phenol to the exposed nail matrix for 1-3 minutes to destroy germinal cells, then neutralizing with alcohol. 3, 6, 5
Alternative matricectomy methods include electrocautery, radiofrequency ablation, or direct surgical excision of the nail matrix – all have similar efficacy when properly performed. 3, 7, 5
For distal ingrowth or very hypertrophic lateral folds, debulking the soft tissue (removing excess granulation tissue and hypertrophied lateral nail fold) is most effective. 7, 5
Recurrent Cases
Partial nail avulsion with phenol matricectomy is the gold standard for preventing recurrence – significantly superior to conservative approaches or nail avulsion without matricectomy. 3, 5
Complete nail avulsion is rarely necessary and should be reserved for cases with extensive nail plate involvement or multiple failed partial procedures. 3, 7
Common Pitfalls to Avoid
Never underestimate ingrown nails in diabetic patients – what appears minor can rapidly progress to limb-threatening infection due to neuropathy, PAD, and impaired immune function. 2, 4
Avoid prescribing oral antibiotics alone without addressing the mechanical problem – the ingrown nail edge will continue traumatizing tissue regardless of antibiotic coverage. 3, 6
Do not perform surgical procedures on diabetic patients with PAD without first assessing vascular status (toe pressures, TcPO2) – poor perfusion dramatically increases infection and non-healing risk. 1, 4
Repeated debridement without correcting underlying factors (improper footwear, poor nail trimming technique, foot deformities) leads to rapid recurrence. 6, 5
Chemical matricectomy requires proper technique – inadequate phenol application time or failure to reach the full depth of the matrix results in recurrence, while excessive application causes unnecessary tissue damage. 3, 7