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Ingrown Toenail Management Reviewed

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Charles Vega, MD, FAAFP
  • CME Released: 2/20/2009
  • Valid for credit through: 2/20/2010, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, orthopaedists, and other specialists who care for patients with ingrown toenails.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. List factors that should prompt consideration for immediate surgical therapy for ingrown toenails.
  2. Describe the surgical management of ingrown toenails.


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  • Laurie Barclay, MD

    Laurie Barclay, MD, is a freelance reviewer and writer for Medscape LLC.


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Charles P. Vega, MD, FAAFP

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Charles Vega, MD, FAAFP, has disclosed an advisor/consultant relationship to Novartis, Inc.

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Ingrown Toenail Management Reviewed

Authors: News Author: Laurie Barclay, MD CME Author: Charles Vega, MD, FAAFPFaculty and Disclosures

CME Released: 2/20/2009

Valid for credit through: 2/20/2010, 11:59 PM EST


February 20, 2009 — A review published in the February 15 issue of American Family Physician discusses risk factors, conservative therapy, and surgical approaches regarding management of the ingrown toenail in primary care.

"Approximately 20 percent of patients presenting to a family physician with a foot problem have an ingrown toenail, also known as onychocryptosis," write Joel J. Heidelbaugh, MD, and Hobart Lee, MD, from the University of Michigan in Ann Arbor. "Ingrown toenails occur when the periungual skin is punctured by its corresponding nail plate, resulting in a cascade of foreign body, inflammatory, infectious, and reparative processes. Ultimately, this may result in a painful, draining, and foul-smelling lesion of the involved toe (most commonly, the hallux nail), with soft tissue hypertrophy around the nail plate."

Anatomic and behavioral factors that may predispose to onychocryptosis may include incorrect methods of nail trimming, repetitive or unintentional trauma, genetic risk factors, hyperhidrosis, and poor foot hygiene. Wider nail folds and thinner, flatter nails are thought to increase the risk for ingrown toenails, but this is still unproven.

To help prevent onychocryptosis, toenails should be cut straight across and not pointed or too short, and the corners should not be rounded off.

Medical conditions associated with onychocryptosis include diabetes, obesity, as well as thyroid, cardiac, and kidney diseases that may predispose to lower extremity edema.

Ingrown toenail can be characterized as mild to moderate, in which the lesion gives rise to minimal to moderate pain with pressure, little erythema, and no purulent drainage. Mild cases are associated with nail-fold swelling and edema, and moderate cases with increased swelling, possible seropurulent drainage, infection, and ulceration of the nail fold.

Moderate to severe ingrown toenail is associated with severe, disabling pain, marked erythema, and purulent drainage. In the most severe cases of onychocryptosis, there is chronic inflammation, granulation, and marked nail-fold hypertrophy. Even for moderate to severe lesions, antibiotic use is not routinely recommended because it has not been shown to decrease healing time, postoperative morbidity, or recurrence rates.

Indications for the treatment of ingrown toenail include significant pain or infection; deformed, curved nail known as onychogryposis; or chronic, recurrent nail-fold inflammation (paronychia).

Conservative approaches to therapy are appropriate for initial management of mild to moderate ingrown toenail. These may include foot soaks in warm, soapy water and application of topical antibiotic ointment or mid-potency to high-potency steroid cream or ointment; placement of cotton wisps or dental floss under the edge of the ingrown toenail; and gutter splinting, which may sometimes involve the placement of a sculptured acrylic nail.

When conservative therapy fails for initial management of moderate to severe onychocryptosis, surgical treatments may be appropriate, such as partial nail avulsion or complete nail excision with or without phenolization. For treatment of ingrown toenails, partial nail avulsion followed by either phenolization or direct surgical excision of the nail matrix is equally effective.

For the prevention of symptomatic recurrence of ingrown toenails, partial avulsion of the lateral nail plate plus phenolization has been shown to be more effective than surgical excision of the nail without phenolization. However, the risk for postoperative infection is slightly increased with avulsion plus phenolization. Administration of oral antibiotics before or after phenolization has not been shown to improve outcomes.

When there is postoperative recurrence with pain and infection, the germinal matrix tissue should be permanently destroyed with phenolization (application of 80% - 88% phenol solution), electrocautery, radiofrequency, or carbon dioxide laser ablation of the the nail matrix.

Contraindications to surgical therapy include allergy to local anesthetics, bleeding disorder, or pregnancy if phenol use is considered.

All patients undergoing toenail surgery should receive appropriate education regarding postoperative care.

Specific recommendations for clinical practice, and their accompanying level of evidence rating, are as follows:

  • For the treatment of ingrown toenails without infection, conservative approaches include use of a cotton wisp, dental floss, or gutter splint (with or without acrylic nail) under the lateral edge of the ingrown nail (level of evidence, C).
  • Before or after phenolization, administration of oral antibiotics does not decrease healing rates or rates of postprocedure morbidity (level of evidence, B).
  • For the treatment of onychocryptosis, partial nail avulsion followed by phenolization or direct surgical excision of the nail matrix is equally effective (level of evidence, B).
  • Partial nail avulsion combined with phenolization is more effective at preventing symptomatic recurrence of ingrown toenails vs surgical excision of the nail without phenolization, but it carries a slightly increased risk for postoperative infection (level of evidence, B).

"Overaggressive electrocautery or radiofrequency ablation to the nail matrix may damage the adjacent and underlying fascia or periosteum," the review authors conclude. "If the toe is healing poorly several weeks after the procedure, debridement, oral antibiotics, and radiographic evaluation may be warranted. Patients should be instructed before the procedure that the appearance of the affected nail will be permanently altered and that the recess created by the removal of the nail and granulation tissue will gradually resolve to a somewhat normal appearance."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;79:303-308.

Clinical Context

Ingrown toenails are a common problem in primary care practices, and many factors have been hypothesized to contribute to abnormal toenail growth and ingrown toenails. These factors include anatomic variations such as wider nail folds and thinner, flatter nails. In addition, genetics, family history, hyperhidrosis, trauma, and poor foot hygiene may also promote ingrown toenails. Finally, diseases that promote lower extremity edema can contribute to a higher risk for ingrown toenail. However, limited clinical data support most of these factors as risks for ingrown toenails.

The current review describes the characterization and management of ingrown toenails.

Study Highlights

  • Mild ingrown toenails are characterized by nail-fold swelling, erythema, edema, and pain with pressure. These lesions may be treated with conservative management.
  • Moderate ingrown toenails demonstrate increased swelling and seropurulent drainage. Severe cases exhibit chronic inflammation and granulation, along with significant nail-fold hypertrophy. Moderate and severe ingrown toenails should be considered for prompt surgical management.
  • Conservative therapy can include soaking the affected toe in warm, soapy water for 10 to 20 minutes. Soaks may be followed by application of a topical antibiotic ointment or mid-potency to high-potency steroid cream.
  • Patients may also manage mild ingrown toenails by placing wisps of cotton or dental floss under the lateral edge of the ingrown nail. This practice may immediately reduce pain and does not appear to increase the risk for infection.
  • Alternatively, a gutter splint can be created by cutting vinyl intravenous drip infusion tubing along its length. This splint can be fitted over the lateral edge of the ingrown nail and held in place with either adhesive tape or a formable acrylic resin such as cyanoacrylate.
  • Adjunctive systemic antibiotics are usually unnecessary for patients receiving partial avulsion of the nail edge and matricectomy. Antibiotics do not improve outcomes vs ablation of the nail bed with phenol (phenolization).
  • The authors of the current review recommend brief application of a tourniquet during nail avulsion. They also promote cutting the affected part of the nail with a hemostat before removing the nail.
  • Partial nail avulsion followed by phenolization is equally as effective as direct surgical excision of the nail matrix.
  • Adding phenolization to surgical excision of an ingrown toenail reduces the risk for recurrence, albeit at a cost of a slightly higher risk for postoperative infection.
  • Excessive application of phenol could result in prolonged oozing of the toenail wound.
  • Ferric chloride solutions can decrease nail bed oozing, but they can also, on rare occasions, promote local thrombosis.
  • Partial matricectomy may also be accomplished with electrocautery, radiofrequency, and carbon dioxide laser ablation.
  • Patients may soak the affected foot 24 to 48 hours after the surgery and then apply antibiotic ointment and a new bandage. This postoperative care should continue 3 to 4 times daily for 1 to 2 weeks after the procedure.

Pearls for Practice

  • Although pain, edema, and erythema may be present in mild cases of ingrown toenails, the presence of seropurulent drainage should prompt consideration of surgical management.
  • The current review recommends phenolization of the nail matrix to prevent a recurrent ingrown toenail. A tourniquet for the toe is recommended during the surgery for ingrown toenails, and patients may soak their toe 24 to 48 hours after the procedure. Systemic antibiotics are generally unnecessary when the ingrown toenail is removed surgically.


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