What is the recommended initial management of an ingrown toenail?

Initial Management of Ingrown Toenail

For uncomplicated ingrown toenails, begin with conservative management using topical povidone-iodine 2% twice daily combined with mid-to-high potency topical corticosteroid ointment to the nail folds twice daily, along with mechanical relief measures; reserve surgical intervention for cases that fail to improve after 2 weeks or for severe presentations with deep abscess formation. 1, 2

Conservative First-Line Approach

Topical Antiseptic and Anti-inflammatory Therapy

• Apply topical povidone-iodine 2% twice daily as the most evidence-based first-line antiseptic agent 1, 2, 3
• Apply mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation and edema 1, 2, 3
• Important caveat: Avoid topical steroids if purulent drainage is present until infection is adequately treated 1, 2

Adjunctive Soaking Measures

• Perform daily dilute vinegar soaks (50:50 dilution with water) to nail folds for 10-15 minutes twice daily 1, 2
• Alternatively, use warm water soaks for 15 minutes 3-4 times daily 3

Mechanical Relief Techniques

• Tape the nail fold away from the nail plate to reduce pressure 1
• Place cotton wisps or dental floss under the ingrown nail edge to separate it from underlying tissue 1, 4
• Consider gutter splinting to the ingrown nail edge for immediate pain relief 4

When to Add Oral Antibiotics

Indications for Antibiotic Therapy

• Prescribe oral antibiotics only if signs of infection are present (pain with discharge, nail plate separation, or purulent drainage) 1, 3
• First-line agents: Cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) for 1-2 weeks 1, 3
• If cephalexin fails: Switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 3
• Avoid clindamycin as first-line therapy due to inadequate streptococcal coverage and increasing resistance 3

Culture Guidance

• Obtain bacterial/viral/fungal cultures before starting antibiotics if infection is suspected, as up to 25% of cases have bacterial or fungal superinfections involving both gram-positive and gram-negative organisms 1, 2, 3

Reassessment and Escalation Criteria

Two-Week Checkpoint

• Reassess after 2 weeks of conservative management 1, 2, 3
• If no improvement occurs, escalate to surgical intervention 1, 2

Immediate Surgical Indications

• Severe infections with deep abscess, extensive tissue involvement, or substantial necrosis require immediate surgical consultation 1
• Intolerable symptoms despite conservative therapy warrant surgical management 1, 3
• Recurrent or treatment-refractory cases need surgical intervention 1, 5

Critical Pitfalls to Avoid

• Do not delay surgical intervention beyond 2 weeks if medical management fails 1, 2
• Do not use topical steroids in the presence of purulent drainage 1, 2
• Do not prescribe clindamycin as first-line therapy 1
• Do not skip obtaining cultures in moderate-to-severe cases before starting antibiotics 3

Patient Education for Prevention

• Instruct patients to trim nails straight across and not too short 6, 3
• Recommend wearing comfortable, well-fitting shoes and cotton socks 6, 3
• Advise avoiding repeated trauma or excessive pressure to toes 6
• Encourage daily application of topical emollients to cuticles and periungual tissues 6, 3