Treatment of Ingrown Toenails
Begin with daily antiseptic soaks using dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily, combined with mid- to high-potency topical corticosteroid ointment applied to the nail folds twice daily. 1, 2
Initial Conservative Management
Antiseptic Therapy
- Apply 2% povidone-iodine twice daily as the most evidence-based first-line antiseptic agent 2
- Alternatively, use dilute vinegar soaks (50:50 dilution) for 10-15 minutes twice daily to reduce inflammation and prevent infection 1, 2
- Continue soaking regimen throughout the treatment course 1
Anti-Inflammatory Treatment
- Immediately after soaking, apply mid- to high-potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation and edema 1, 2
- Critical caveat: Do not use topical steroids if purulent drainage is present 2
- The ointment vehicle is preferred over cream for better penetration in the periungual area 1
Mechanical Relief Techniques
Simple Interventions
- Insert dental floss or cotton wisps under the ingrown lateral nail edge to separate it from underlying tissue 1, 3
- Tape the nail fold away from the nail plate to reduce pressure 2
- Consider placing a plastic tube with a lengthwise incision on the lateral edge of the nail to encapsulate it (gutter splinting) 1, 4
Management of Infection
When to Obtain Cultures and Start Antibiotics
- If pus is present, obtain bacterial cultures before initiating antibiotics 1, 2
- Up to 25% of cases have bacterial or fungal superinfections 2
- For mild-to-moderate infections, prescribe cephalexin or amoxicillin-clavulanate for 1-2 weeks with Staphylococcus aureus coverage 2, 5
- Do not prescribe clindamycin as first-line therapy 2
- Continue antibiotics for 1-2 weeks for mild infections; moderate-to-severe infections may require 2-4 weeks 2
Management of Granulation Tissue
Stepwise Approach
- If granulation tissue persists despite topical corticosteroids, consider adding topical timolol 0.5% gel twice daily under occlusion 1, 5
- For small granulomas that persist, use silver nitrate chemical cauterization 1, 5
- Alternative options include scoop shave removal with hyfrecation 1
- Cryotherapy can be considered as an alternative destructive modality 5
Treatment for Recurrent or Severe Cases
Oral Antibiotic Therapy
- For recurrent, severe, or treatment-refractory cases after 2-4 weeks, prescribe doxycycline 100 mg twice daily with follow-up after one month 1
When to Escalate to Surgery
- Reassess after 2 weeks of medical management; if no improvement, escalate to surgical intervention 2, 5
- Persistent pain or drainage beyond 2-4 weeks requires surgical intervention 1
- Severe infections with deep abscess, extensive tissue involvement, or substantial necrosis require immediate surgical consultation 2
- Partial nail avulsion combined with phenolization is more effective than surgical excision alone at preventing symptomatic recurrence, though it carries a slightly increased risk of postoperative infection 3, 6
Prevention of Recurrence
Patient Education
- Trim toenails straight across, never rounded at corners, and avoid cutting too short 1, 5
- Wear comfortable, well-fitting shoes with adequate toe room and cotton socks to prevent pressure and friction 1, 5
- Apply topical emollients daily to cuticles and periungual tissues to maintain skin barrier function 1, 5
- Avoid cutting cuticles or manipulating the nail folds 1
- Wear protective gloves when working with water or chemicals 1
- Maintain good hand hygiene 1
- Avoid artificial nails and harsh nail products 1
Post-Treatment Monitoring
Follow-Up Schedule
- Reassess wound healing at 2 weeks post-procedure to determine if additional interventions are needed 1
- Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 1
- Continue antiseptic soaks if inflammation persists 1