What is the recommended management of onychocryptosis (ingrown toenail)?

Treatment of Ingrown Toenails

For mild-to-moderate ingrown toenails without severe infection, start with conservative management including topical povidone-iodine 2% twice daily, dilute vinegar soaks, and mechanical relief measures; if no improvement after 2 weeks, proceed to surgical partial nail avulsion with matricectomy. 1

Initial Conservative Management

Antiseptic and Anti-inflammatory Therapy

• Apply topical povidone-iodine 2% twice daily as the first-line antiseptic agent 1
• Perform dilute vinegar soaks (50:50 dilution) to the nail fold for 10-15 minutes twice daily 1, 2
• Apply mid-to-high potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation and edema, but avoid if purulent drainage is present 1, 2

Mechanical Relief Measures

• Tape the nail fold away from the nail plate to reduce pressure 1
• Place cotton wisps or dental floss under the ingrown nail edge to separate it from underlying tissue 1, 3
• Consider gutter splinting of the ingrown nail edge for immediate pain relief 3

Footwear and Nail Care

• Recommend comfortable, well-fitting shoes with adequate toe box to reduce external pressure 1
• Instruct patients to trim nails straight across and avoid cutting them too short 1
• Do not cut into the nail corners, as this worsens lateral impingement and increases recurrence risk 1

Antibiotic Therapy for Infected Cases

Indications for Antibiotics

• Prescribe antibiotics when purulent discharge, extensive swelling, or bacterial superinfection is present (occurs in up to 25% of cases) 1
• For mild-to-moderate infections, prescribe cephalexin or amoxicillin-clavulanate for 1-2 weeks 1
• If pus is present, obtain cultures and initiate antibiotics with coverage against Staphylococcus aureus and gram-positive organisms 2

Duration of Antibiotic Therapy

• Continue antibiotics for 1-2 weeks for mild infections, with some requiring an additional 1-2 weeks 1
• For moderate-to-severe infections, 2-4 weeks is usually sufficient 1

Reassessment and Surgical Escalation

Timing of Reassessment

• Reassess after 2 weeks of medical management; if no improvement, escalate to surgical intervention 1

Indications for Immediate Surgery

• Severe infections with deep abscess, extensive tissue involvement, or substantial necrosis require immediate surgical consultation 1
• Recurrent or treatment-refractory cases warrant surgical management 1, 4
• Intolerable grade 2 or grade 3 ingrown toenail severity after failed conservative treatment 1

Surgical Management

Preferred Surgical Approach

• Partial nail avulsion combined with matricectomy (chemical phenolization or surgical excision) is the most effective approach for preventing recurrence 5
• Partial nail avulsion with phenolization is more effective at preventing symptomatic recurrence compared to surgical excision without phenolization, though it carries a slightly increased risk of postoperative infection 5
• Complete nail avulsion followed by topical antifungal therapy showed disappointing results in randomized controlled trials and is NOT recommended as routine treatment 4, 2

Chemical Matricectomy Technique

• Phenolization is equally effective as direct surgical excision of the nail matrix 5
• Oral antibiotics before or after phenolization do not improve outcomes 5

Critical Pitfalls to Avoid

• Do not delay surgical intervention beyond 2 weeks if medical management fails 1
• Do not use topical steroids in the presence of purulent drainage 1, 2
• Do not prescribe clindamycin as first-line therapy 1
• Do not perform complete nail avulsion for routine ingrown toenail treatment, as evidence shows disappointing results 4, 2

Special Considerations for Diabetic Patients

• Ingrown or thickened toenails in diabetic patients require immediate treatment by an appropriately trained healthcare professional to prevent ulceration 4
• Assess for signs of infection or poor circulation before proceeding with any nail removal, as diabetic patients have higher complication risk 4
• Consider digital flexor tendon tenotomy rather than nail removal as first-line surgical intervention for diabetic patients at risk of foot ulceration 4