eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Toenails, Ingrown: Treatment & Medication
Updated: Jul 24, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
Once nails have started to grow in, the basement membranes of the cuticle are open to bacterial invasion and action is needed to forestall progression.
- The edge of the nail should be elevated from the bed. This elevation can be accomplished by simply rolling a cotton wisp from the lateral side of the nail gently under the edge of the nail (in the case of a lateral ingrowth). Forcing the cotton wisp in from the tip is much more painful.
- If the nail is too ingrown to do this without pain, try soaking the foot in warm water with an antibacterial agent. Soaking may soften the nail enough to allow elevation of the edge without much pain.
Emergency Department Care
These conservative measures should be enacted as soon as possible and may be sufficient to render surgical treatment unnecessary.
- If soaking fails, perform a digital block (outlined below) before elevating the nail edge. The toe is exquisitely sensitive. The block may hurt more than the procedure if it is not performed slowly with a small (30-gauge) needle and buffered lidocaine.
- Partial nail removal with cauterization of the nail matrix is curative in 70-90% of cases.
- Alternatively, part of the nail plate may be removed by laser. However, there is little to no advantage to the use of the laser over chemical cautery.
- Chemical cautery of the nail matrix can be done by using phenol or 10% sodium hydroxide.
- Obtain informed consent; consent should be obtained by the physician and not delegated. Make no guarantees of cure or lack of complications; explain the risk of infection, regrowth, and reoccurrence; and discuss the proposed procedure.
- Prepare and drape the toe by using povidone-iodophor or a skin cleanser of choice, and perform a digital block at the metatarsal head or proximal phalanx. Use buffered lidocaine (usually without epinephrine, although there is no evidence to support this recommendation), and inject 1 mL at each digital nerve.
- Using a nail cutter, elevate the ingrown portion of the nail, rolling the nail from the ingrown side toward the midline of the toe. Be sure to expose the germinal end of the nail. (This end has a soft, feathered edge.) The proximal end is under the cuticle and usually is white. Cut about one-fourth to one-third of the nail, perpendicular to the end of the nail. Discard the piece after showing it the patient.
- Place a cotton-tipped applicator, soaked in super-saturated phenol or 10% sodium hydroxide, into the proximal sulcus exposed by removal of the germinal portion of the nail. Wait 60 seconds; repeat this step. Rinse the site, especially the sulcus, with rubbing alcohol. Use an alcohol-saturated applicator to ensure removal of all chemical.
- Apply a light gauze dressing, and instruct the patient to change the gauze the next day and then daily for 3-5 days. The patient should expect a slight discharge as the body cleanses the nail bed. Importantly, this discharge should occur as the site improves in appearance; discharge and increasing signs of inflammation may mean infection or an incomplete removal of the nail fragments.
Also see, Ingrown Toenail Removal.
Consultations
Consultation is encouraged for those patients with risk factors (e.g., those with diabetes or compromised circulation), related to either the disease or the procedure.Medication
Medications are needed for only those with complications. Antibiotics are not indicated unless lymphangitic spread is noted. Antifungal agents are needed for onychomycosis. Ibuprofen is used for pain.
Analgesics
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Most analgesics have sedating properties, which are beneficial for patients who have painful lesions.
Ibuprofen (Advil, Motrin, Nuprin, and Genpril)
Usually the label directions are sufficient for the treatment of mild to moderate pain, if no contraindications are present. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 30-70 mg/kg/d PO tid/qid; not to exceed 2.4 g/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, decreased renal and hepatic function, anticoagulation abnormalities, or during anticoagulant therapy
Acetaminophen (Tylenol, Aspirin Free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or those taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg PO tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; many OTC products contain acetaminophen, and combined use may result in cumulative acetaminophen doses exceeding recommended maximum dose
Acetaminophen and Codeine (Tylenol with codeine)
Drug combination indicated for the treatment of mild to moderate pain.
Adult
30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab PO q4h; not to exceed 12 tabs in 24 h
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content PO; not to exceed 2.6 g/d of acetaminophen
Toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates (substitution may result in acute opiate-withdrawal symptoms); caution in severe renal or hepatic dysfunction
More on Toenails, Ingrown |
| Overview: Toenails, Ingrown |
| Differential Diagnoses & Workup: Toenails, Ingrown |
 Treatment & Medication: Toenails, Ingrown |
| Follow-up: Toenails, Ingrown |
| Multimedia: Toenails, Ingrown |
| References |
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References
Barker LR, Burton JR, Zieve PD. Principles of Ambulatory Medicine. 3rd ed. Williams & Wilkins; 1991.
Bossers AM, Jansen IM, Eggink WF. Rational therapy for ingrown toenails. A prospective study. Acta Orthop Belg. 1992;58(3):325-9. [Medline].
Fulton GJ, O'Donohoe MK, Reynolds JV, Keane FB, Tanner WA. Wedge resection alone or combined with segmental phenolization for the treatment of ingrowing toenail. Br J Surg. Jul 1994;81(7):1074-5. [Medline].
Giacalone VF. Phenol matricectomy in patients with diabetes. J Foot Ankle Surg. Jul-Aug 1997;36(4):264-7; discussion 328. [Medline].
Ingrown toenails. Last updated May 2007. Familydoctor.org. Available at http://familydoctor.org/online/famdocen/home/common/skin/disorders/208.html.
Kimata Y, Uetake M, Tsukada S, Harii K. Follow-up study of patients treated for ingrown nails with the nail matrix phenolization method. Plast Reconstr Surg. Apr 1995;95(4):719-24. [Medline].
Mori H, Umeda T, Nishioka K, et al. Ingrown nails: a comparison of the nail matrix phenolization method with the elevation of the nail bed-periosteal flap procedure. J Dermatol. Jan 1998;25(1):1-4. [Medline].
Ozdemir E, Bostanci S, Ekmekci P, Gurgey E. Chemical matricectomy with 10% sodium hydroxide for the treatment of ingrowing toenails. Dermatol Surg. Jan 2004;30(1):26-31. [Medline].
Sauer GC. Manual of Skin Diseases. JB Lippincott; 1985.
Wollina U. Modified Emmet's operation for ingrown nails using the Er:YAG laser. J Cosmet Laser Ther. May 2004;6(1):38-40. [Medline].
Zaborszky Z, Fekete L, Tauzin F, Orgovan G. Treatment of ingrowing toenail with segmental chemical ablation. Acta Chir Hung. 1997;36(1-4):398-400. [Medline].
Further Reading
Keywords
ingrown toenail, sore toe, sore toenail, painful toe, swollen toe, unguis incarnatus, mycoses, chemical cautery, tender toe, diabetes, arterial insufficiency, lymphangitis
