How should I manage an ingrown toenail, and when is surgery indicated, particularly in patients with diabetes or peripheral vascular disease?

Management of Ingrown Toenails

In diabetic patients or those with peripheral vascular disease, ingrown toenails should be treated conservatively by trained foot care professionals, with surgical intervention reserved only for cases failing conservative management after vascular assessment confirms adequate perfusion.

Initial Assessment in High-Risk Patients

Before any intervention, assess vascular status in all diabetic patients and those with suspected peripheral arterial disease (PAD):

• Measure ankle-brachial index (ABI) - if <0.9, this indicates PAD and requires vascular surgery referral before any surgical treatment of the ingrown nail 1
• For diabetic patients, ABI is unreliable - measure toe pressure waves instead before considering surgical intervention 1
• Check for loss of protective sensation using 10g Semmes-Weinstein monofilament testing 2, 3
• Palpate pedal pulses and assess for signs of ischemia (rubor on dependency, pallor on elevation) 3

Critical pitfall: Three case reports document patients requiring hallux amputation or major vascular bypass surgery after routine ingrown toenail procedures were performed without recognizing underlying PAD 1. This emphasizes the absolute necessity of vascular screening before any surgical intervention.

Conservative Management (First-Line for All Patients)

Professional treatment by trained foot care specialists should be the initial approach for all ingrown toenails in diabetic patients:

• Proper nail trimming and care by appropriately trained healthcare professionals 4
• Nail brace application is a safe, simple, and inexpensive option that provides immediate symptom relief in diabetic patients with ingrown nails without suppuration or granulation tissue 5
  • In one study, 15 of 21 diabetic patients (71%) remained recurrence-free for 2 years after brace treatment 5
  • Patients preferred repeat brace application over surgery even when recurrence occurred 5
• Integrated foot care every 1-3 months including professional nail treatment, education, and therapeutic footwear for high-risk diabetic patients 4, 2

When Surgery Is Indicated

Surgical intervention should only be considered after conservative treatment fails AND adequate vascular perfusion is confirmed:

Pre-Surgical Requirements:

• Confirm ABI >0.5 or ankle pressure >50 mmHg (or adequate toe pressures in diabetics) 4, 1
• Ensure no active infection - if infection present, treat with antibiotics and debridement first 4
• Rule out critical ischemia - if present, urgent vascular imaging and revascularization must precede any foot surgery 4

Surgical Options:

Chemical matricectomy with 10% sodium hydroxide is effective and safe in diabetic patients when vascular status is adequate:

• Apply after partial nail avulsion for 1 minute preceded by matrix curettage 6
• No significant difference in healing, infection rates, or recurrence compared to non-diabetic patients in controlled study 6
• Complete healing achieved with 24-month follow-up showing comparable outcomes 6

Phenolization should be avoided in patients with PAD - case reports show catastrophic outcomes including amputation when performed without adequate vascular assessment 1

Special Considerations for Diabetic Patients

Post-operative infection risk is 9.5% in diabetic neuropathy patients, requiring careful patient selection and close follow-up 2, 7

Provide structured patient education on:

• Daily foot inspection using mirrors if needed 3
• Never walking barefoot or in thin-soled slippers 3
• Immediate reporting of any signs of infection (fever, increased pain, drainage, worsening hyperglycemia) 4

Ensure proper footwear - prescribe extra-depth shoes with wide toe-box to prevent recurrence and accommodate any deformities 2, 7

Follow-up is critical - patients with treated ingrown nails require early and careful observation to ensure treatment effectiveness and detect complications early 4

Algorithm Summary

1. Screen for vascular disease (ABI or toe pressures) and neuropathy (monofilament testing)
2. If adequate perfusion present: Start conservative management with professional nail care ± nail bracing
3. If conservative treatment fails after appropriate trial: Consider chemical matricectomy with 10% sodium hydroxide
4. If ABI <0.9 or inadequate perfusion: Refer to vascular surgery BEFORE any surgical nail procedure
5. If infection present: Treat infection first with antibiotics and debridement before addressing the ingrown nail 4