Ingrown Toenails Treatment & Management

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.^[4]

• 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.

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.^[5]
• Alternatively, part of the nail plate may be removed by laser.^[6] 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.^{[7, 8, 9, 10]}

  • 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 (this is shown in the photo below). 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. Cutting the nail.
  • 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 (shown in the photo below). 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. Cauterizing the matrix.
  • The toe after the completed procedure is shown in the photo below.Appearance of toenail at end of the cauterizing procedure.
  • 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.

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.^[11]