What is the appropriate initial management for an ingrown toenail?

Initial Management of Ingrown Toenail

For mild to moderate ingrown toenails, begin with conservative treatment including warm water soaks, placement of cotton wisps or dental floss under the ingrown nail edge, and gutter splinting, reserving surgical partial nail avulsion with phenolization for moderate to severe cases or conservative treatment failures. 1, 2

Conservative Management (First-Line for Mild Cases)

Immediate Measures

• Soak the affected foot in warm, soapy water or Epsom salt solution for 10-15 minutes twice daily to reduce inflammation and soften the nail fold 1, 3
• Apply a mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 4, 2
• Place cotton wisps or dental floss under the ingrown lateral nail edge to lift the nail away from the inflamed tissue 1, 2

Adjunctive Conservative Techniques

• Apply a gutter splint to the ingrown nail edge to separate it from the lateral fold, which provides immediate pain relief 2
• Consider daily dilute vinegar soaks (50:50 dilution) for 10-15 minutes twice daily as an adjunctive antiseptic measure 4, 5
• Correct inappropriate footwear that compresses the toes and manage contributing factors like hyperhidrosis 2

Patient Education

• Teach proper nail trimming technique: cut toenails straight across rather than curved to prevent recurrence 6, 7
• Address behavioral factors including proper foot hygiene and appropriate footwear selection 1, 2

When to Escalate to Antibiotics

Infection Assessment

• Look for signs of secondary infection: purulent drainage, increased erythema beyond the nail fold, warmth, or worsening pain despite conservative measures 4, 8
• If infection is suspected, obtain bacterial/viral/fungal cultures before initiating antibiotics 4, 5
• Recognize that secondary infection occurs in up to 25% of cases, involving both gram-positive and gram-negative organisms 4

Antibiotic Selection

• Initiate oral antibiotics with coverage against Staphylococcus aureus and gram-positive organisms if infection is confirmed 4, 8
• Avoid topical steroids if purulent drainage is present until infection is adequately treated 4

Surgical Intervention Indications

When Conservative Treatment Fails

• Reassess after 2 weeks; if no improvement with conservative measures, escalate to surgical intervention 4, 5
• Surgical approaches are superior to nonsurgical ones for preventing recurrence 2

Surgical Approach

• Partial nail avulsion combined with phenolization is the most effective treatment for preventing symptomatic recurrence 1
• This approach is more effective than surgical excision without phenolization, though it carries a slightly increased risk of postoperative infection 1
• Administer local anesthesia for pain control before the procedure 5

Post-Surgical Management

• Apply topical povidone iodine 2% as the most evidence-based first-line antiseptic agent 4, 5
• Combine with topical antibiotics and corticosteroids to reduce inflammation 4, 5
• Cut nails regularly until the nail plate grows reattached to prevent permanent onycholysis 5
• Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 5

Common Pitfalls to Avoid

• Do not delay surgical intervention beyond 2 weeks if conservative treatment shows no improvement, as this can lead to chronic inflammation and increased risk of complications 4, 5
• Avoid curved nail trimming, which is a primary behavioral contributor to ingrown toenails 6, 7
• Do not use prophylactic oral antibiotics before or after phenolization, as they do not improve outcomes 1
• Ensure meticulous nail bed cleaning and repair during any surgical procedure to prevent complications 5