What are the recommended treatment options for managing ingrown toenails, particularly in patients with a history of diabetes or impaired circulation?

Management of Ingrown Toenails

In patients with diabetes or impaired circulation, ingrown toenails must be treated by trained healthcare professionals rather than through self-care, with treatment frequency every 1-3 months for high-risk patients to prevent progression to ulceration. 1

Risk Stratification in Diabetic Patients

Before treating an ingrown toenail in a diabetic patient, assess their ulceration risk using the IWGDF system:

• Screen for peripheral neuropathy using 10g Semmes-Weinstein monofilament testing and assess for peripheral artery disease by checking pedal pulses 1, 2
• Classify risk level: Patients with loss of protective sensation or PAD are automatically at increased risk (IWGDF risk 1-3) 1
• Ingrown toenails in diabetic patients with neuropathy or PAD are considered pre-ulcerative lesions requiring immediate professional intervention 3, 2

Treatment Algorithm by Patient Population

For Diabetic or Vascular Compromise Patients (High Priority)

Conservative Management (First-Line):

• Professional nail care only—never allow self-treatment or use of chemical agents 3
• Trained healthcare professionals should perform proper nail trimming (cut straight across) and remove any associated callus 1
• Schedule regular professional foot care every 1-3 months for high-risk patients (IWGDF risk 3) or every 3-6 months for moderate-risk patients (IWGDF risk 2) 1, 3
• Prescribe extra-depth shoes with wide toe-box to reduce pressure on affected toes 3, 2
• Educate patients to inspect feet daily and immediately contact healthcare professionals if inflammation or drainage develops 1

Surgical Intervention (When Conservative Fails):

• Digital flexor tenotomy is the preferred surgical approach for diabetic patients with flexible hammertoes and ingrown nails with pre-ulcerative signs, achieving 92-100% healing rates in 21-40 days 3, 2
• This outpatient procedure requires no subsequent immobilization and has recurrence rates of only 0-20% over 11-36 months 3, 2
• Important caveat: Post-operative infection risk is 9.5% in diabetic neuropathy patients, requiring careful patient selection 3, 2

For Non-Diabetic Patients Without Vascular Compromise

Stage 1 (Mild): Erythema, slight edema, pain with pressure

• Soak foot in warm, soapy water 4, 5
• Place cotton wisps or dental floss under the ingrown nail edge to elevate it 4, 5, 6
• Apply gutter splint to separate nail from lateral fold for immediate pain relief 6
• Correct improper footwear and nail-trimming technique 4, 5
• Apply mid- to high-potency topical steroid after soaking 6

Stage 2 (Moderate): Worsening symptoms, drainage, infection

• Continue conservative measures or proceed to surgical intervention 4
• Consider oral antibiotics if cellulitis is present, though antibiotics do not improve outcomes when combined with phenolization 5
• Gutter splinting or cotton nail cast with cyanoacrylate adhesive may provide relief 6

Stage 3 (Severe): Lateral wall hypertrophy, granulation tissue

• Partial nail avulsion with lateral matricectomy is the definitive treatment 4, 5, 6
• Chemical matricectomy with phenol is highly effective and prevents recurrence better than surgical excision alone, though it carries slightly increased infection risk 5, 6
• Electrosurgical matricectomy offers more controlled tissue destruction and less postoperative drainage compared to phenol 4
• Complete nail excision is rarely necessary and has higher recurrence rates 5

Critical Pitfalls to Avoid

• Never allow diabetic patients to perform self-treatment of ingrown toenails, as they lack protective sensation and cannot detect early infection 3
• Do not delay professional treatment in diabetic patients—ingrown nails are pre-ulcerative lesions that can rapidly progress to ulceration 3, 2
• Avoid narrow or tight footwear that increases pressure on affected toes, particularly in diabetic patients 1, 2
• Do not use oral antibiotics routinely before or after phenolization, as they do not improve outcomes 5
• Screen for hyperhidrosis and onychomycosis, as these contribute to ingrown nail development and must be managed concurrently 5, 6

Prevention Strategies

• Educate all at-risk patients to cut toenails straight across rather than curved 1
• Daily foot inspection is mandatory for diabetic patients to detect early signs of ingrown nails 1
• Wear properly fitting footwear that accommodates foot shape, with shoe length 1-2 cm longer than the foot 2
• Apply emollients daily to maintain skin elasticity and prevent nail problems 1
• Never walk barefoot or in thin-soled slippers, whether indoors or outdoors 1