What is the recommended management for an ingrown toenail?

Management of Ingrown Toenail

For mild ingrown toenails, begin with antiseptic soaks using dilute vinegar or 2% povidone-iodine twice daily for 10-15 minutes, followed immediately by application of mid- to high-potency topical corticosteroid ointment to the affected nail fold twice daily. 1

Initial Conservative Management

The first-line approach for mild ingrown toenails focuses on reducing inflammation and preventing infection without surgical intervention:

• Perform antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution) or 2% povidone-iodine solution 1, 2
• Apply mid- to high-potency topical corticosteroid ointment to the inflamed nail fold twice daily immediately after soaking to reduce local inflammation 1, 2
• Consider mechanical separation techniques such as placing cotton wisps or dental floss under the ingrown lateral nail edge, or using gutter splinting with a plastic tube placed on the lateral nail edge, or taping the lateral nail fold away from the nail plate 1, 3, 4

Antibiotic Use: When and How

Do not routinely prescribe antibiotics for mild ingrown toenails unless clear signs of infection are present. 1

Antibiotics are indicated only when:

• Purulent drainage is present requiring culture 1
• Localized cellulitis with significant erythema extends beyond the nail fold 1
• Coverage should target Staphylococcus aureus and gram-positive organisms, as secondary infection occurs in up to 25% of cases 5, 2

For recurrent or treatment-refractory cases:

• Use doxycycline 100 mg twice daily with follow-up after one month 1
• Obtain bacterial/viral/fungal cultures before initiating oral antibiotics in grade 2 or higher cases 2

When to Escalate to Surgery

Reassess after 2 weeks of conservative management and escalate to surgical consultation if: 1

• Persistent pain or drainage continues beyond 2-4 weeks despite appropriate conservative therapy 1
• Granulation tissue develops 1
• Painful hematoma or subungual abscess is suspected, requiring partial or total nail avulsion 5

Surgical approaches are superior to nonsurgical ones for preventing recurrence, with partial nail avulsion combined with phenolization being more effective than surgical excision alone, though it carries a slightly increased risk of postoperative infection. 3, 4

Prevention Education: Critical for Long-Term Success

Patient education is critical to prevent recurrence and should include: 1

• Trim toenails straight across, not too short 1, 6
• Wear comfortable and well-fitting shoes to avoid excessive pressure 5, 1
• Apply topical emollients daily to cuticles and periungual tissues 5, 1
• Avoid manipulating cuticles or using nails as tools 5, 1
• Wear protective gloves when working with water or chemicals 5, 1

Special Population: Diabetic Patients

For diabetic patients, provide more aggressive monitoring and prompt treatment by trained healthcare professionals, as ingrown toenails can progress to foot ulceration with significant morbidity. 1

• Integrated foot care should be provided every 1-3 months in diabetic patients 1

Common Pitfalls to Avoid

• Avoid topical steroids if purulent drainage is present until infection is adequately treated 2
• Do not aggressively trim nails or attempt to cut away ingrown portions, as this can worsen inflammation 6
• Do not delay surgical referral if conservative management fails after 2 weeks 1, 2