Ingrown Toenail Management

 

Am Fam Physician. 2019 Aug 1;100(3):158-164.

  Patient information: See related handout on ingrown toenail management, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Ingrown toenails account for approximately 20% of foot problems in primary care. The great toe is most often affected. Ingrown toenails occur most commonly in young men, and nail care habits and footwear are most often contributory factors. No consensus has been reached for the best treatment approach, but ingrown nails may be nonsurgically or surgically treated. Nonsurgical treatments are typically used for mild to moderate ingrown nails, whereas surgical approaches are used in moderate and severe cases. Simple nonsurgical palliative measures include correcting inappropriate footwear, managing hyperhidrosis and onychomycosis, soaking the affected toe followed by applying a mid- to high-potency topical steroid, and placing wisps of cotton or dental floss under the ingrown lateral nail edge. Application of a gutter splint to the ingrown nail edge to separate it from the lateral fold provides immediate pain relief. A cotton nail cast made from cotton and cyanoacrylate adhesive, taping the lateral nail fold, or orthonyxia may also alleviate mild to moderate ingrown toenail. Surgical approaches seek to remove the interaction between the nail plate and the nail fold to eliminate local trauma and inflammatory reaction. These approaches are superior to nonsurgical ones for preventing recurrence. The most common surgical approach is partial avulsion of the lateral edge of the nail plate. Matrixectomy further prevents recurrence and can be performed through surgical, chemical, or electrosurgical means.

Ingrown nail, also known as onychocryptosis or unguis incarnatus, represents approximately 20% of foot problems presenting to family physicians.1 It occurs when the periungual skin of the lateral nail fold is traumatized by its adjacent nail plate, resulting in an inflammatory foreign body reaction.2,3 This often results in a painful, draining, foul-smelling lesion and hypertrophy of the involved nail fold.4,5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Surgical approaches are recommended for moderate to severe ingrown toenails to prevent recurrence.2

B

Cochrane review of 24 studies of varying methodologic quality

Equally effective treatments for ingrown toenails are partial nail avulsion followed by phenolization or direct surgical excision of the nail matrix.5

B

Single-center randomized controlled trial with 58 participants

Oral antibiotics are not recommended for ingrown toenail unless there is cellulitis.1

B

Single-center randomized controlled trial with 54 participants

Partial nail avulsion with phenolization is more effective at preventing symptomatic recurrence than surgical excision without phenolization.2

B

Cochrane review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Surgical approaches are recommended for moderate to severe ingrown toenails to prevent recurrence.2

B

Cochrane review of 24 studies of varying methodologic quality

Equally effective treatments for ingrown toenails are partial nail avulsion followed by phenolization or direct surgical excision of the nail matrix.5

B

Single-center randomized controlled trial with 58 participants

Oral antibiotics are not recommended for ingrown toenail unless there is cellulitis.1

B

Single-center randomized controlled trial with 54 participants

Partial nail avulsion with phenolization is more effective at preventing symptomatic recurrence than surgical excision without phenolization.2

B

Cochrane review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Ingrown toenail most commonly affects the great toe and is more common in young men.2,6,7 Risk factors include anatomic and physiologic mechanisms and grooming techniques, including excessive or improper trimming of the lateral nail plate. Repetitive toe trauma (e.g., running, kicking), inadvertent nail injury, wearing constricting footwear, and the reduced ability to care for one's nails are also risk factors3,4 (Figure 18).

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FIGURE 1.

Examples of improper and proper toenail trimming. Toenails should be cut straight across, and the corners should not be rounded off.

Reprinted with permission from Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303.


FIGURE 1.

Examples of improper and proper toenail trimming. Toenails

The Authors

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E.J. MAYEAUX, JR., MD, DABFP, FAAFP, DABPM, is a professor and chairman in the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine and a chairman in the Palmetto Health Medical Group, Columbia....

CHARLES CARTER, MD, FAAFP, is a professor in the Department of Family Medicine at the University of South Carolina School of Medicine and Palmetto Health System and an associated designated institutional official for Graduate Medical Education, Columbia.

TENLEY E. MURPHY, MD, FAAFP, CAQSM, is assistant professor in the Department of Family and Preventive Medicine at the University of South Carolina School of Medicine and Palmetto Health System and director of the Palmetto Health Primary Care Sports Medicine Fellowship program, Columbia.

Address correspondence to E.J. Mayeaux, Jr., MD, 3209 Colonial Dr., Columbia, SC 29203. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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