How should onychocryptosis be managed?

Treatment of Ingrown Toenails (Onychocryptosis)

For ingrown toenails, begin with conservative measures including daily dilute vinegar soaks, taping the nail fold away from the nail plate, and cotton packing or dental floss insertion under the ingrown edge; reserve surgical intervention with partial nail avulsion and phenol matricectomy for recurrent, severe, or treatment-refractory cases. 1

Initial Conservative Management

Start with these non-surgical interventions for early-stage ingrown toenails:

• Daily dilute vinegar soaks (50:50 dilution) to the nail folds twice daily for 10-15 minutes to reduce inflammation and prevent secondary infection 1

• Apply mid to high potency topical steroid ointment to the nail folds twice daily to reduce edema and pain 1

• Tape the nail fold away from the nail plate to separate the inflamed tissue from the sharp nail edge 1

• Insert dental floss under the ingrown nail edge to separate the lateral nail from the underlying tissue and allow proper growth 1

• Cotton packing or cast edge separation can be used as an alternative to dental floss for lifting the nail edge 1

Management of Infection

If pus is present, obtain bacterial cultures before starting antibiotics and initiate oral coverage against Staphylococcus aureus 2:

• Cephalexin 500mg four times daily for 7-10 days as first-line therapy 2
• Amoxicillin-clavulanate 875/125mg twice daily for 7-10 days as an alternative 2
• Topical 2% povidone-iodine can be added as adjunctive antiseptic treatment 1, 2

Stop or avoid topical steroids once infection is identified to prevent worsening of bacterial proliferation 1

Management of Granulation Tissue

When periungual pyogenic granulomas develop:

• Silver nitrate application for chemical cauterization of small granulation tissue 1
• Scoop shave removal with hyfrecation for larger or persistent granulation tissue 1
• High-potency topical steroids applied to the granulation tissue 1
• Topical timolol 0.5% gel twice daily under occlusion as an alternative anti-granulation therapy 1

Advanced Conservative Techniques

For persistent cases not responding to basic measures:

• Splinting with a flexible tube placed on the lateral edge of the nail with a lengthwise incision to encapsulate the sharp edge 1
• Acrylic treatment with gutter splint using formable acrylic for fixation of the splint and nail prosthesis 1
• Combination topical therapy with antibiotics and corticosteroids for cases with both inflammation and infection risk 1

Surgical Intervention

Reserve surgical treatment for recurrent, severe, or treatment-refractory ingrown toenails 1, 3:

• Partial nail avulsion with phenol matricectomy is the most effective, safe, and commonly performed surgical method 3
• Phenol cauterization of the lateral nail matrix provides definitive treatment with low recurrence rates 3
• Surgical procedures are indicated when conservative measures fail after appropriate trial 4

Critical Surgical Safety Considerations

Be aware of rare but serious surgical complications:

• Phenol burns can occur if technique is improper, potentially leading to tissue necrosis requiring amputation 5
• Surgical site infections can progress to gangrene in rare cases, particularly in young patients 6
• Proper wound care and infection monitoring are essential in the postoperative period 6

Treatment Algorithm by Severity

Stage 1 (Early inflammation without infection):

• Vinegar soaks + topical steroids + taping + dental floss insertion 1

Stage 2 (Infection present):

• Add oral antibiotics (cephalexin or amoxicillin-clavulanate) + culture if pus present 2
• Stop topical steroids 1

Stage 3 (Granulation tissue formation):

• Silver nitrate or scoop shave removal + continue conservative measures 1

Recurrent/Severe/Treatment-Refractory:

• Intralesional triamcinolone acetonide for persistent inflammation 1
• Doxycycline 100mg twice daily for recurrent paronychia with follow-up after 1 month 1
• Surgical referral for partial matricectomy if conservative measures fail 3, 4

Common Pitfalls to Avoid

• Do not continue topical steroids in the presence of active infection, as this will worsen bacterial proliferation 1
• Do not proceed directly to surgery without attempting conservative measures in early-stage disease 3, 4
• Ensure proper phenol application technique if performing chemical matricectomy to avoid burns 5
• Monitor surgical patients closely for infection given rare but devastating complications 6