How should I manage an ingrown toenail (onychocryptosis)?

Management of Ingrown Toenail

Start with conservative management for mild to moderate ingrown toenails, including warm antiseptic soaks, topical steroids, and gutter splinting, but proceed to partial nail avulsion with phenolization for severe cases or when conservative treatment fails after 2 weeks. 1

Initial Assessment

Evaluate the severity by examining for:

• Degree of redness and edema in the lateral nail fold 1
• Presence of purulent discharge or abscess formation requiring drainage 1
• Granulation tissue formation (pyogenic granuloma) 1
• Pain level and functional impairment 2

Conservative Management (First-Line for Mild to Moderate Cases)

Antiseptic Soaking Protocol

• Perform warm antiseptic soaks with dilute vinegar (50:50 dilution with water) or povidone-iodine for 10-15 minutes twice daily 1
• Apply topical 2% povidone-iodine directly to the affected area twice daily between soaks 1

Anti-Inflammatory Treatment

• Apply mid to high-potency topical steroid ointment to the nail folds twice daily to reduce inflammation 1

Mechanical Relief Techniques

• Gutter splinting provides immediate pain relief: place a plastic tube on the lateral edge of the nail to separate it from the inflamed nail fold 1, 2
• Alternatively, place cotton wisps or dental floss under the ingrown nail edge to lift it away from the lateral fold 3, 2

Antimicrobial Therapy for Infected Cases

When to Start Antibiotics

• Initiate oral antibiotics when purulent discharge, significant pain, or spreading erythema is present 1
• Recognize that up to 25% of cases have secondary bacterial or mycological superinfections 1

Antibiotic Selection

• Start with cephalexin as first-line therapy 1
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1
• Consider amoxicillin-clavulanate as an alternative first-line option 4

Surgical Intervention

Indications for Surgery

• Intolerable pain despite conservative management 1
• Presence of painful hematoma or subungual abscess 1
• Recurrent or severe cases unresponsive to 2 weeks of conservative treatment 1

Surgical Approach

• Partial nail avulsion combined with phenolization is more effective than surgical excision alone at preventing recurrence, though it carries a slightly increased risk of postoperative infection 3
• Complete nail excision is reserved for cases with extensive nail plate involvement 3, 5
• Oral antibiotics before or after phenolization do not improve outcomes 3

Management of Pyogenic Granuloma

If excessive granulation tissue develops:

• Perform scoop shave removal with hyfrecation 1
• Apply silver nitrate chemical cauterization 1
• Consider topical timolol 0.5% gel twice daily under occlusion for refractory cases 1
• Intralesional triamcinolone acetonide may be used for recurrent or treatment-refractory granulomas 1

Prevention Strategies

Nail Care Education

• Trim nails straight across, avoiding excessive shortening or rounding of corners 1, 2
• Avoid trauma from tight footwear or repetitive pressure 1

Footwear and Hygiene

• Wear comfortable, well-fitting shoes with adequate toe box space 1
• Use cotton socks to manage moisture 1
• Manage hyperhidrosis if present, as excessive moisture contributes to recurrence 2

Follow-Up Protocol

• Reassess after 2 weeks of conservative treatment 1
• If no improvement occurs after 2 weeks, refer to dermatology or podiatry for surgical evaluation rather than continuing ineffective conservative measures 1

Critical Pitfalls to Avoid

• Do not delay surgical referral in severe cases, as rare but serious complications including gangrene requiring amputation have been reported following inadequate management of surgical site infections 6
• Avoid cutting nails too short or creating sharp edges, which perpetuates the ingrown nail cycle 1, 2
• Do not rely solely on antibiotics without addressing the mechanical problem of the ingrown nail 1