How should an infected ingrown toenail be managed?

Treatment of Infected Ingrown Toenail

For mild to moderate infected ingrown toenails, start oral antibiotics targeting Staphylococcus aureus (cefalexin, dicloxacillin, or trimethoprim-sulfamethoxazole) combined with warm water soaks and proper wound care; severe infections require immediate surgical consultation and intravenous antibiotics. 1

Severity Assessment

First, classify the infection severity to guide treatment:

• Mild infection: Local inflammation, pain, and minimal discharge limited to the toe 2
• Moderate infection: More extensive inflammation, purulent discharge, pain limiting instrumental activities of daily living 2
• Severe infection: Significant inflammation extending beyond the toe, systemic symptoms (fever, chills), or signs of deep tissue involvement such as crepitus, necrosis, or gangrene 3, 4

Antibiotic Therapy by Severity

Mild Infections

Oral antibiotics for 1-2 weeks targeting gram-positive cocci are sufficient: 1, 2

• First-line options: Cefalexin or dicloxacillin 1, 2
• Alternative first-line: Trimethoprim-sulfamethoxazole or amoxicillin-clavulanate 1, 2
• Penicillin allergy: Clindamycin or doxycycline 1, 2

Avoid broad-spectrum antibiotics for mild infections in antibiotic-naive patients—therapy aimed solely at aerobic gram-positive cocci is sufficient. 1, 2

Moderate Infections

Oral antibiotics for 2-4 weeks: 1, 2

• Trimethoprim-sulfamethoxazole, amoxicillin-clavulanate, levofloxacin, or clindamycin 1, 2
• Consider obtaining wound cultures if the patient has recently received antibiotics or if MRSA is suspected 1

Severe Infections

Immediate hospitalization with intravenous antibiotics: 1, 2

• Initial IV therapy: Piperacillin-tazobactam, OR levofloxacin/ciprofloxacin plus clindamycin 1, 2
• If MRSA suspected: Add vancomycin 30 mg/kg/day in 2 divided doses 2
• For gram-negative coverage: Consider ceftriaxone 1
• Duration: Continue until infection resolves (typically 2-4 weeks), not necessarily until wound heals 3

Essential Concurrent Local Measures

Antibiotics alone are insufficient—proper wound care is crucial: 3

• Warm water soaks or Epsom salt soaks 2-3 times daily 5, 6
• Povidone-iodine 2% soaks or dilute vinegar soaks (50:50 dilution) twice daily 1, 2
• Sharp debridement of necrotic tissue and callus 3
• Correct improper footwear and manage hyperhidrosis 6
• Topical antibiotics with corticosteroids for inflammation 2

When to Obtain Cultures

• Generally unnecessary for acute mild infections in antibiotic-naive patients 1
• Obtain cultures for moderate-to-severe infections, prior antibiotic failure, suspected MRSA, or no improvement after 2-5 days of therapy 1, 2

Surgical Consultation Indications

Seek immediate surgical consultation for: 3, 4

• Deep abscess formation 3
• Crepitus (gas in soft tissues—indicates necrotizing infection) 4
• Extensive necrosis or gangrene 3, 4
• Necrotizing fasciitis 3, 4
• Failure to respond to antibiotics within 2-5 days 1

Surgical options include partial nail avulsion with phenolization or matricectomy, which are superior to conservative treatment for preventing recurrence. 6, 7

MRSA Coverage Considerations

Add MRSA-directed therapy (trimethoprim-sulfamethoxazole, clindamycin, or vancomycin) if: 2

• Prior MRSA infection 2
• Recent antibiotic exposure 2
• Failure of initial beta-lactam therapy 2
• High local MRSA prevalence 3

Follow-Up Monitoring

• Reassess within 2-5 days for outpatient treatment 1, 2
• If no improvement: Obtain cultures, consider changing antibiotics, or pursue surgical intervention 1
• If worsening: Escalate to higher level of care and broader antibiotic coverage 3

Critical Pitfalls to Avoid

• Do not delay surgical intervention for severe infections while waiting for imaging—clinical judgment supersedes imaging, and delays increase mortality 4
• Do not use antibiotics without concurrent wound care—this approach frequently fails 3
• Do not continue ineffective antibiotics—if no response after one course in a stable patient, discontinue antibiotics for a few days and obtain optimal cultures 3