How do you treat an ingrown toenail?

Treatment of Ingrown Toenails

Start with conservative management using antiseptic soaks and topical steroids for mild cases, escalate to partial nail avulsion with phenolization for moderate-to-severe or treatment-refractory cases after 2 weeks of failed conservative therapy. 1, 2

Initial Conservative Management (First-Line for Mild Cases)

Antiseptic Soaks and Topical Therapy

• Perform warm antiseptic soaks twice daily for 10-15 minutes using either dilute vinegar (50:50 dilution) or 2% povidone-iodine solution 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area as the most evidence-based antiseptic 3
• Use mid-to-high potency topical corticosteroid ointment to nail folds twice daily immediately after soaking to reduce inflammation and edema 1, 2
• Stop topical steroids immediately if purulent drainage develops 1, 3

Mechanical Relief Techniques

• Gutter splinting with a plastic tube placed on the lateral nail edge provides immediate pain relief 1, 2
• Cotton wisp or dental floss insertion under the ingrown lateral nail edge separates it from underlying inflamed tissue 2, 4
• Taping the lateral nail fold away from the nail plate reduces pressure 1, 3

Antibiotic Therapy (When Infection is Present)

Indications for Antibiotics

• Do not routinely prescribe antibiotics unless clear signs of infection are present, such as purulent drainage or cellulitis extending beyond the nail fold 2
• Up to 25% of cases develop bacterial or fungal superinfections requiring antimicrobial therapy 1, 3

Antibiotic Selection

• Start with cephalexin as first-line therapy for mild-to-moderate infections 1
• Amoxicillin-clavulanate is an alternative first-line option 3
• Switch to sulfamethoxazole-trimethoprim (Bactrim) if initial treatment fails, providing broader coverage including MRSA 1
• Continue antibiotics for 1-2 weeks for mild infections; moderate-to-severe infections may require 2-4 weeks 3
• For recurrent, severe, or treatment-refractory cases, use doxycycline 100 mg twice daily with follow-up after one month 2

Surgical Intervention

Timing and Indications

• Reassess after 2 weeks of conservative management 2, 3
• Escalate to surgical consultation if no improvement after 2 weeks of appropriate conservative therapy 2, 3
• Partial nail avulsion is indicated for intolerable pain despite conservative management or when pain persists beyond 2-4 weeks 1, 3
• Immediate surgical consultation is required for severe infections with deep abscess, extensive tissue involvement, or substantial necrosis 3

Surgical Approach

• Partial nail avulsion followed by phenolization is more effective at preventing symptomatic recurrence compared to surgical excision alone, though it carries a slightly increased risk of postoperative infection 5
• Partial nail avulsion with either phenolization or direct surgical excision of the nail matrix are equally effective treatment options 5

Management of Granulation Tissue

• Scoop shave removal with hyfrecation or silver nitrate application for pyogenic granuloma formation 1
• High-potency topical steroids or topical timolol 0.5% gel twice daily under occlusion can be considered 1
• Intralesional triamcinolone acetonide for recurrent or severe cases 1

Prevention of Recurrence

Patient Education (Critical Component)

• Trim toenails straight across, not too short, and avoid cutting into corners 2, 3
• Wear comfortable, well-fitting shoes with adequate toe box and cotton socks 1, 3
• Apply topical emollients daily to cuticles and periungual tissues 2
• Avoid manipulating cuticles or using nails as tools 2
• Wear protective gloves when working with water or chemicals 1, 2

Special Population: Diabetic Patients

• Diabetic patients require more aggressive monitoring and prompt treatment by trained healthcare professionals 2
• Ingrown toenails can progress to foot ulceration with significant morbidity in diabetics 2
• Provide integrated foot care every 1-3 months for diabetic patients 2

Critical Pitfalls to Avoid

• Do not delay surgical intervention beyond 2 weeks if medical management fails 3
• Do not use topical steroids in the presence of purulent drainage 1, 3
• Do not prescribe clindamycin as first-line therapy 3
• Oral antibiotics before or after phenolization do not improve outcomes and should not be routinely used 5