Management of ingrown toenails
Initial management of an ingrown toenail should be conservative. Resolution is often slow (7 to 14 days).
Advise the patient to avoid or minimise exposure to precipitating factors, if possible; see Causes of ingrown toenails. Provide analgesia and remove pressure from the toe and nail while it heals (eg wearing open toe shoes, padding with gauze). To prevent the ingrown toenail from recurring, advise the patient to cut the distal free edge of the nail in a straight line and not to cut the nail too short.
Gently lift the nail edge out of the lateral nail fold. To make it easier to lift the corners of the nail, file down the centre of the nail until it is thin and the pink nail bed is visible. Pack moistened cotton wool (eg soaked in alcohol 70%) beneath the nail to keep the distal nail plate elevated. Repack the nail daily until the toe is healed.
Apply a topical antiseptic if there are signs of infection. For example, use:
povidone-iodine 10% ointment topically, under occlusion. povidone-iodine povidone-iodine povidone-iodine
Sometimes a spicule of nail remains in the skin of the lateral nail fold, which can cause infection. Look for this and remove it. Local anaesthesia may be required. If the lateral nail fold suppurates or cellulitis develops around the toe, oral antibiotics are required. Take a swab of the area for microscopy and culture. Sometimes empirical antibiotics are started while waiting for culture and sensitivity results. Use:
1dicloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days dicloxacillin dicloxacillin dicloxacillin
OR
1flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days. flucloxacillin flucloxacillin flucloxacillin
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin1, use:
cefalexin 1 g (child: 25 mg/kg up to 1 g) orally, 12-hourly for 5 days. cefalexin cefalexin cefalexin
For patients who have had a severe (immediate or delayed)2 hypersensitivity reaction to a penicillin, use:
1clindamycin 450 mg (child 1 month or older: 10 mg/kg up to 450 mg) orally, 8-hourly for 5 days clindamycin clindamycin clindamycin
OR
1trimethoprim+sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly for 5 days. trimethoprim + sulfamethoxazole trimethoprim+sulfamethoxazole trimethoprim+sulfamethoxazole
If there is inflammation and swelling, consider using a potent topical corticosteroid:
1betamethasone dipropionate 0.05% ointment topically, once daily for 3 to 5 days betamethasone dipropionate betamethasone dipropionate betamethasone dipropionate
OR
1methylprednisolone aceponate (adult, or child 4 months or older) 0.1% fatty ointment topically, once daily for 3 to 5 days methylprednisolone aceponate methylprednisolone aceponate methylprednisolone aceponate
OR
1mometasone furoate 0.1% ointment topically, once daily for 3 to 5 days. mometasone furoate mometasone furoate mometasone furoate
Granulation tissue can be treated with curettage, or light application of a silver nitrate cautery stick or a potent topical corticosteroid. If granulation tissue around the nail does not respond to treatment, refer for specialist assessment; further investigation may be needed for differential diagnoses (eg acral melanoma).
If the ingrown toenail is impacting daily function, recurrent, or persisting despite conservative therapy, further surgical intervention may be required (eg nail wedge resections)—refer for specialist advice (eg podiatrist, dermatologist).