Management of Ingrown Toenail in Infants
For an infant with an ingrown toenail, begin with conservative management including warm antiseptic soaks, topical steroids, and proper nail care, but be prepared to proceed with surgical wedge resection of hypertrophic soft tissues if conservative measures fail, as this condition in infants often presents as a congenital bilateral problem requiring definitive surgical treatment. 1, 2
Initial Assessment
Evaluate the infant's toenail for:
- Bilateral involvement (highly suggestive of congenital ingrown toenail) 2
- Pain, tenderness, and erythema at the distal hallux 2
- Purulent discharge or signs of infection 2
- Hypertrophy of skin and fat at the distal end of the great toe extending over the dorsum of the nail plate 2
- Presence of inflammatory or infectious granulation tissue 2
This presentation differs from typical ingrown toenails in older children and adults, as congenital ingrown toenails in infants are rare and present at birth or shortly thereafter with characteristic bilateral involvement and excessive periungual soft tissue. 2
Conservative Management (First-Line)
Implement the following measures initially:
- Warm antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1
- Topical 2% povidone-iodine applied twice daily to the affected area 1, 3
- Mid to high-potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 3
- Proper nail trimming: Keep toenails trimmed straight across, not too short 4
- Gentle skin care with daily application of topical emollients to cuticles and periungual tissues 4
Antibiotic Therapy (If Infection Present)
If signs of infection develop:
- Start with cephalexin as first-line oral antibiotic 1, 3
- If initial treatment fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1, 3
- Obtain bacterial cultures before starting antibiotics in severe cases 3
- Be aware that up to 25% of cases have secondary bacterial or fungal superinfections 1, 3
Surgical Intervention (When Conservative Fails)
For infants with congenital ingrown toenails, surgical treatment is often necessary and highly effective:
- Wedge resection of hypertrophic soft tissues at the distal end of the toe is the definitive treatment for congenital ingrown toenails in infants 2
- This procedure provides excellent results with resolution of the condition and no recurrences 2
- Surgical approaches are superior to nonsurgical ones for preventing recurrence in general 5
- Consider partial nail avulsion if pain is intolerable despite conservative management 1
The key distinction in infants is that congenital ingrown toenails often involve excessive periungual soft tissue rather than just nail plate problems, making soft tissue debulking more appropriate than nail plate procedures. 2, 6
Critical Pitfalls to Avoid
- Do not delay surgical referral if conservative measures fail after 2 weeks, as congenital ingrown toenails in infants typically require definitive surgical treatment 1, 2
- Do not perform aggressive nail trimming or attempt to cut away ingrown portions in infants, as this can worsen inflammation 4
- Do not overlook bilateral involvement, which is characteristic of congenital cases and requires evaluation of both feet 2
- Do not assume simple nail care habits are causative in infants, as this is typically a congenital anatomical problem rather than acquired 2
Follow-Up Protocol
- Reassess after 2 weeks of conservative treatment 1, 3
- If no improvement or worsening occurs, refer to pediatric surgery or podiatry for surgical evaluation 1, 3
- Expect excellent outcomes with surgical wedge resection in infants with no recurrences 2