What is the treatment for an ingrown toenail, especially in patients with conditions like diabetes that affect circulation and healing?

Treatment of Ingrown Toenail

In diabetic patients or those with poor circulation, ingrown toenails require immediate evaluation and treatment by a trained healthcare professional, as they represent a pre-ulcerative sign with significant risk of progression to serious foot ulceration, infection, and amputation. 1

Immediate Risk Stratification

For diabetic patients, immediately assess:

• Vascular status by palpating dorsalis pedis and posterior tibial pulses to detect peripheral artery disease 1
• Peripheral neuropathy using 10-g monofilament testing to determine loss of protective sensation 1
• Signs of infection including purulent drainage, erythema extending beyond the nail fold, cellulitis, abscess formation, warmth, or systemic symptoms 1
• IWGDF risk category: Risk 0 (no neuropathy), Risk 1 (neuropathy alone), Risk 2 (neuropathy plus deformity or PAD), Risk 3 (prior ulcer/amputation) 1

Patients in Risk categories 2-3 require urgent specialist referral due to high amputation risk. 1

Treatment Algorithm by Patient Risk

For Diabetic or High-Risk Patients (with neuropathy, PAD, or prior ulceration):

Do not attempt home treatment or delay professional care. 1

• Immediate professional treatment by trained foot care specialist to remove the offending nail portion using sterile technique 1
• Prescribe appropriate therapeutic footwear that accommodates foot shape, with shoes 1-2 cm longer than the foot and adequate toe box height 1, 2
• Offload pressure from the affected toe using shoe modifications, toe spacers, or orthoses 3, 1
• If infection is present (erythema, warmth, purulent drainage):
  • For mild superficial infection: cleanse, debride necrotic tissue, start empiric oral antibiotics targeting S. aureus and streptococci 3
  • For moderate-to-severe infection: urgent surgical evaluation for debridement, obtain tissue cultures (not swabs) from wound base, initiate parenteral broad-spectrum antibiotics 3, 4
• If PAD is present with ankle pressure <50 mmHg or ABI <0.5: consider urgent vascular imaging and revascularization 3

For Non-Diabetic, Low-Risk Patients:

For mild-to-moderate ingrown toenails without infection:

• Conservative management first:
  • Soak foot in warm water with Epsom salt 5
  • Place cotton wisps or dental floss under the ingrown nail edge to lift it away from the nail fold 6, 7
  • Apply gutter splint to separate the nail edge from the lateral fold for immediate pain relief 6
  • Apply mid-to-high potency topical steroid to reduce inflammation 6
  • Correct inappropriate footwear that compresses toes 1, 6

For moderate-to-severe cases or failed conservative treatment:

• Surgical partial nail avulsion combined with phenolization is the most effective treatment to prevent recurrence, though it carries slightly increased infection risk compared to avulsion alone 7
• Alternative surgical options include complete nail excision, electrocautery, radiofrequency, or CO2 laser ablation of the nail matrix 7
• For diabetic patients specifically, nail brace application is a safe, simple, non-surgical option that provides immediate symptom relief, though recurrence may occur 8

Critical Management Principles

Do not prescribe prophylactic antibiotics for uninfected ingrown toenails—this promotes antibiotic resistance without benefit. 1, 4

Debride all necrotic tissue and surrounding callus with sharp debridement when treating any associated wound. 3

If bone is visible or palpable with sterile probe, suspect osteomyelitis and obtain imaging. 1

Monitor for fungal superinfection if not responding to treatment—up to 25% develop secondary fungal infections requiring antifungal therapy. 1, 4

Patient Education for Prevention

Teach proper nail trimming technique: cut toenails straight across, not curved. 1, 9

Instruct diabetic patients to:

• Inspect feet daily, including between toes, for any new lesions 1, 2, 4
• Wash feet daily with careful drying between toes 1, 4
• Apply emollients to dry skin but avoid between toes 1
• Contact healthcare provider immediately if new lesions develop 1, 2
• Limit prolonged standing and walking if neuropathy is present 3, 2

Ensure follow-up until complete resolution and monitor for recurrence. 1