What is the best course of action for an adult experiencing painful swollen toes?

Management of Painful Swollen Toes in Adults

For an adult with painful swollen toes, immediately assess for diabetes status and signs of infection, then initiate appropriate offloading, proper footwear, and treat any underlying pathology such as ingrown toenails, pre-ulcerative lesions, or infection—with diabetic patients requiring urgent evaluation by a trained foot care specialist within 1-3 months. 1, 2

Immediate Assessment Priorities

Rule Out Infection First

• Look for purulent drainage, significant erythema extending beyond the toe, warmth, or cellulitis that would require immediate antibiotic coverage targeting Staphylococcus aureus and streptococci 1, 2
• If infection is present, initiate empiric oral antibiotics before any other interventions 1
• For diabetic patients, infection can rapidly progress to foot ulceration with significant morbidity, requiring immediate professional treatment 2

Identify Diabetes Status

• Diabetic patients with painful swollen toes are at moderate-to-high risk (IWGDF risk 2-3) and require integrated foot care every 1-3 months 1, 2
• Check for loss of protective sensation using 10-g monofilament testing plus at least one other assessment (pinprick, vibration with 128-Hz tuning fork, or ankle reflexes) 1
• Assess vascular status by palpating dorsalis pedis and posterior tibial pulses 1

Examine for Specific Pathology

• Ingrown toenails: Check for nail penetrating the nail fold, surrounding inflammation, and granulation tissue 2
• Pre-ulcerative lesions: Look for hyperkeratotic tissue (callus), erythema, warmth, or areas of increased pressure over bony prominences 1, 3
• Hammertoes or deformities: Assess for rigid or non-rigid deformities causing abnormal pressure distribution 1
• Fungal infections: Examine for onychomycosis or interdigital fungal infection 1, 2

Treatment Algorithm

For Ingrown Toenails

• Perform antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 2
• Apply mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 2
• If onychomycosis is present, initiate appropriate antifungal therapy based on culture results 2
• Educate on proper nail trimming: cut toenails straight across, never rounded at corners, and avoid cutting too short 1, 2

For Pre-Ulcerative Lesions or Callus

• Remove all hyperkeratotic tissue immediately through sharp debridement with scalpel, scissors, or tissue nippers performed by a trained healthcare professional 3
• This reduces pressure at the affected site, removes colonizing bacteria, and permits full examination of tissue involvement 3
• Repeat debridement sessions as often as needed if nonviable tissue continues to form 3
• Select dressings based on wound characteristics: hydrogels for dry wounds, alginates or foams for exudative wounds 3

Footwear Management (Critical for All Patients)

• Immediate action: Instruct patient not to walk barefoot, in socks only, or in thin-soled slippers, whether indoors or outdoors 1
• Prescribe properly fitted footwear with internal length 1-2 cm longer than the foot, width equal to the metatarsal phalangeal joints, and adequate height for toes 1
• For patients with foot deformities or pre-ulcerative signs, prescribe extra-depth shoes, custom-made footwear, or custom-made insoles 1
• Therapeutic footwear must demonstrate ≥30% reduction in plantar pressure compared to standard footwear 1, 3

Pain Management

• Administer NSAIDs (e.g., ibuprofen) for pain control and inflammation reduction 4
• Monitor for GI side effects, particularly in patients on long-term NSAID therapy 4
• Avoid NSAIDs in patients with aspirin-sensitive asthma, coagulation disorders, or those on anticoagulants 4

Daily Self-Care Education (All Patients)

• Wash feet daily with careful drying, particularly between the toes 1, 2
• Apply emollients to moisturize dry skin 1, 2
• Examine feet daily for any changes or new lesions 1, 2
• With presence or suspicion of a pre-ulcerative lesion, rapidly contact a trained healthcare professional 1
• Use other sensory modalities (palpation or visual inspection with a mirror) if protective sensation is lost 1

Red Flags Requiring Urgent Vascular Assessment

• Absent pedal pulses on palpation 1
• Ankle-brachial index <0.9 (or <0.5 for severe ischemia) 1, 3
• Toe pressure <50 mmHg or transcutaneous oxygen pressure (TcPO2) <30 mmHg 1
• Ulcer not improving despite optimal treatment after 6 weeks 1, 3
• If vascular compromise is identified, consider revascularization before healing can occur 1, 3

Common Pitfalls to Avoid

• Never debride ischemic ulcers without signs of infection as this can worsen tissue damage 1
• Do not prescribe conventional or standard therapeutic shoes to heal plantar foot ulcers—they are ineffective 1
• Avoid topical antimicrobials unless infection is clinically evident 3
• Do not delay referral to specialized foot care for diabetic patients with moderate-to-high risk features 1
• Ill-fitting shoes are the most frequent cause of ulceration, even in patients with ischemic ulcers—always examine footwear meticulously 1

Follow-Up Schedule

• Diabetic patients at moderate-to-high risk (IWGDF risk 2-3): Every 1-3 months for integrated foot care 1, 2
• All patients with pre-ulcerative lesions: Re-evaluate for healing progress and reassess vascular status if no improvement within 6 weeks 3
• Patients with ingrown toenails: Follow up after conservative treatment to assess response and prevent recurrence 2