What is the recommended management for a patient with an ingrown toenail, considering potential underlying conditions such as diabetes?

Management of Ingrown Toenails

Start with conservative management for mild to moderate ingrown toenails in all patients, but proceed directly to partial nail avulsion with phenolization for severe or recurrent cases, with special attention to diabetic patients who require professional foot care and more aggressive intervention to prevent ulceration. 1

Initial Assessment

Evaluate the severity and identify high-risk features:

• Check for infection signs including erythema, pain, swelling, and purulence that require urgent intervention 1
• In diabetic patients, assess for peripheral neuropathy using 10g Semmes-Weinstein monofilament, check pedal pulses for peripheral arterial disease, and determine diabetic foot risk category 2, 1
• Identify contributing factors such as improper nail trimming, ill-fitting footwear, hyperhidrosis, onychomycosis, and trauma 3, 4

Conservative Management (Mild to Moderate Cases)

For non-diabetic patients with mild ingrown toenails, use conservative approaches first:

• Apply gutter splinting to the ingrown nail edge to separate it from the lateral fold, which provides immediate pain relief 4
• Place cotton wisps or dental floss under the ingrown nail edge after soaking the foot in warm, soapy water 3, 4
• Consider resin splint application attached to the lateral nail edge, which achieved pain relief within one week and only 8.2% recurrence rate over 10 months follow-up 5
• Apply mid- to high-potency topical steroid after soaking to reduce inflammation 4

For diabetic patients, professional intervention is mandatory:

• Professional nail care by trained healthcare professionals is required, including proper trimming of the ingrown portion, removal of excess callus, and careful debridement of the nail border 1
• Schedule regular follow-up every 1-3 months for high-risk diabetic patients with neuropathy or peripheral arterial disease 6, 1
• Never allow self-treatment in diabetic patients, especially those with neuropathy 1

Surgical Management (Moderate to Severe Cases)

Partial nail avulsion combined with phenolization is the most effective surgical approach:

• This combination is superior to surgical excision alone for preventing symptomatic recurrence, though it carries a slightly increased risk of postoperative infection 3
• Partial nail avulsion with matrixectomy (chemical, surgical, or electrosurgical) prevents recurrence more effectively than nonsurgical approaches 4
• Alternative techniques include radiofrequency ablation, carbon dioxide laser ablation, and electrocautery of the nail matrix 3, 7

Management of Infected Ingrown Toenails

For infected cases, obtain cultures before starting antibiotics:

• Use broader spectrum coverage and longer duration for moderate infections in diabetic patients 1
• Do not delay treatment in diabetic patients, as infections can rapidly progress to serious complications 1
• Oral antibiotics before or after phenolization do not improve outcomes in non-infected cases 3

Special Considerations for Diabetic Patients

Diabetic patients require heightened vigilance and integrated care:

• Ingrown toenails in diabetic patients with neuropathy or peripheral arterial disease are considered pre-ulcerative lesions requiring immediate intervention 2, 6
• Post-operative infection risk is 9.5% in diabetic neuropathy patients, requiring careful patient selection 6, 1
• Check vascular status before any surgical intervention, as poor circulation impairs healing and increases infection risk 1
• Provide integrated foot care including professional treatment, therapeutic footwear with extra-depth and wide toe-box, and structured education about self-care 6, 1

Prevention and Patient Education

Educate all patients on proper nail care technique:

• Trim nails straight across and not too short to prevent ingrown toenails 1
• Recommend properly fitting footwear that accommodates foot shape, avoiding tight shoes that compress toes 1, 4
• Instruct diabetic patients to inspect feet daily and seek prompt medical attention if problems develop 1
• Manage contributing factors including hyperhidrosis and onychomycosis 3, 4

Common Pitfalls to Avoid

• Never delay treatment in diabetic patients, as progression to ulceration and serious infection occurs rapidly 1
• Avoid self-treatment attempts in high-risk patients, particularly those with neuropathy who may not perceive worsening infection 1
• Be vigilant for coexisting fungal infections that often accompany ingrown nails in diabetic patients 1
• Do not perform surgical intervention without assessing vascular status in diabetic or elderly patients 1