What is the appropriate management for a painful ingrown toenail?

Management of Painful Ingrown Toenail

For a painful ingrown toenail, begin with 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 to the nail fold twice daily, and if conservative measures fail after 2 weeks or if severe inflammation with granulation tissue is present, proceed to partial nail avulsion with phenol matricectomy. 1, 2

Initial Assessment

Before initiating treatment, rule out active infection by examining for:

• Purulent drainage requiring culture 1
• Significant erythema extending beyond the nail fold 2
• Cellulitis requiring antibiotic coverage for Staphylococcus aureus 1

If infection is present, prescribe oral antibiotics with S. aureus coverage such as amoxicillin-clavulanate 500/125 mg every 12 hours, or cephalexin as an alternative. 3, 2

Conservative Management (Mild to Moderate Cases)

Antiseptic soaks and topical therapy:

• Apply 2% povidone-iodine or perform dilute vinegar soaks (50:50 dilution) for 10-15 minutes twice daily 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 1, 2

Mechanical interventions:

• Place cotton wisps or dental floss under the ingrown lateral nail edge to separate it from the underlying tissue 2, 4
• Apply gutter splint using formable acrylic to the lateral nail edge for immediate pain relief 2, 4
• Tape the lateral nail fold away from the nail plate 2

Duration: Reassess after 2 weeks of conservative treatment; if no improvement, escalate to surgical intervention. 3

Surgical Management (Moderate to Severe Cases)

Indications for surgery:

• Failure of conservative treatment after 2 weeks 3
• Presence of pyogenic granuloma (grade 2 or 3) 3
• Recurrent ingrown toenails despite conservative measures 5

Preferred surgical approach:

• Partial nail avulsion of the lateral edge combined with phenol matricectomy is the most effective treatment for preventing symptomatic recurrence 5, 4
• This approach has superior outcomes compared to nail avulsion alone, though carries a slightly increased risk of postoperative infection 5

Alternative surgical options if phenol matricectomy is not available:

• Electrocautery, radiofrequency, or carbon dioxide laser ablation of the nail matrix 5, 6
• Complete nail excision with surgical matricectomy (higher recurrence rates) 5

Management of Pyogenic Granuloma

If granulation tissue develops:

• Apply topical timolol 0.5% gel twice daily under occlusion for persistent granulomas 3, 2
• Consider silver nitrate chemical cauterization for small granulomas 3, 2
• Perform scoop shave removal with hyfrecation for larger lesions 2
• If intolerable or refractory, proceed to surgical excision combined with partial nail avulsion 3

Prevention of Recurrence

Nail care education:

• Cut toenails straight across, never rounded at corners, and avoid cutting too short 1, 3
• Maintain proper foot hygiene with daily washing and careful drying between toes 1

Footwear modifications:

• Ensure well-fitting shoes with adequate toe room 3
• Consider custom-made footwear or orthotic devices if foot deformities are present 1

Treat underlying conditions:

• Address onychomycosis with appropriate antifungal therapy if cultures are positive 1
• Manage hyperhidrosis to reduce moisture-related complications 4

Special Considerations for Diabetic Patients

Critical pitfall: Ingrown toenails in diabetic patients are pre-ulcerative lesions requiring immediate treatment by a trained healthcare professional to prevent progression to foot ulceration with significant morbidity. 1

• Provide integrated foot care every 1-3 months for moderate-to-high risk diabetic patients (IWGDF risk 2-3) 1
• Never attempt self-treatment or delay professional care in diabetic patients 1
• Consider extra-depth shoes or custom footwear if foot deformities are present 1