eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Ingrown Nails: Treatment & Medication

Author: Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Coauthor(s): Ann G Egland, MD, Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Jul 20, 2009

Treatment

Medical Care

Treatment options in patients with ingrown nails depend on the stage of onychocryptosis. Development of ingrown nails is divided into 3 stages (although some have included more1 ): (1) erythema, edema, and focal tenderness; (2) crusting and expressible purulence at the nail fold and nail plate junction; and (3) chronic infection with protuberant granulation tissue extending over the nail plate.1

  • Stage 1 can be managed by recommending shoes with a comfortable wide toe box or open-toed shoes. Instruct the patient's parents to cut the nail straight across and avoid cutting back the lateral margins. The nail edge should extend past the tissue.
  • Stage 2 can be treated by stretching the soft tissue away from the side of the nail, elevating the offending edge of nail from the soft tissue, and placing a small pledget of cotton under the nail edge to lift it back into the nail grove. Instruct patients with stage 2 ingrown nails on how to perform this treatment. Parents should also be instructed to have the child rest, keep the foot elevated, and use warm soaks.
  • Stage 3 should be treated by removing the nail margin in a minor surgical outpatient procedure as described in Surgical Care below. Chronic ingrown toenails may require matrix ablation in addition to other procedures.

Surgical Care

Stage 3 ingrown nails require avulsion of the lateral border of the nail plate with sharp excision of the hypertrophic granulation tissue, as follows:

  • Prepare the digit with Betadine or alcohol if the patient is iodine allergic. Perform a digital block with 2% lidocaine without epinephrine.

    Preparing for digital block before surgical treat...

    Preparing for digital block before surgical treatment of paronychia of right great toe. Universal precautions should always be observed. Photo courtesy of Ann G. Egland, MD.

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    Preparing for digital block before surgical treat...

    Preparing for digital block before surgical treatment of paronychia of right great toe. Universal precautions should always be observed. Photo courtesy of Ann G. Egland, MD.

  • Lift the nail off of the nail matrix bluntly all the way back to approximately one eighth of an inch under the proximal nail fold.
  • Insert a nail anvil and cut the nail back to the proximal nail fold.
  • Remove the free portion of the nail.
  • Protuberant granulation tissue can be removed sharply or treated with silver nitrate.
  • Bleeding, if any, is controlled with pressure.
  • Antibiotic ointment and clean dressing should be applied.

If avulsion has been unsuccessful in the past, partial or total ablation of the nail plate chemically, surgically, or via laser may be indicated. In the past, ablation was usually carried out by electrocautery of the underlying matrix. Caution must be used to avoid affecting tissue deep to the matrix with any ablation procedure or matricectomy. Studies suggest that chemical ablation with phenol6,7 or NaOH8,9 may be superior to cautery or sharp matricectomy.10,11

Many new approaches to the surgical management of ingrown nails have been described, including the following:

  • Wedge resection12
  • The Vandenbos procedure13
  • Lateral foldplasty with or without matricectomy14
  • Laser ablation with or without lateral fold vaporization15
  • Simple plastic tube insertion3
  • Use of a shape-memory alloy device16
  • Use of a super elastic wire device17

Consultations

  • Consult a podiatrist, dermatologist, or orthopedic surgeon for routine follow-up care or for patients in whom primary avulsion therapy has been unsuccessful.
  • Close follow-up care with an orthopedist is required if inflammatory osteophytic changes are observed or if evidence of osteomyelitis is present. Immediate antibiotic treatment should begin, and inpatient treatment may be needed for osteomyelitis.
  • Follow-up with a primary care physician is indicated for any type of immunosuppression, including diabetes mellitus. Guidelines for treatment and prevention of type 2 diabetes mellitus have been established.18  Antibiotics may be started in those who are immunosuppressed.

Diet

  • No dietary limitations are required.

Activity

  • Rest, keep the extremity elevated, keep the site dry, and maintain limited weightbearing until healing has taken place.

Medication

Antibiotics are rarely indicated for ingrown nails. Patients may generally be treated as outpatients. Pain control should be provided.

Analgesic agents

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.


Ibuprofen (Motrin, Advil)

Nonsteroidal anti-inflammatory pain control and treatment of local inflammation.

Adult

200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

8-10 mg/kg PO q6h prn for pain

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; high risk of bleeding

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

Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy


Acetaminophen (FeverAll, Tylenol)

DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

10-15 mg/kg PO q4h prn for pain; not to exceed 2.6 g/d

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum

More on Ingrown Nails

Overview: Ingrown Nails
Differential Diagnoses & Workup: Ingrown Nails
Treatment & Medication: Ingrown Nails
Follow-up: Ingrown Nails
Multimedia: Ingrown Nails
References
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References

  1. Martinez-Nova A, Sanchez-Rodriguez R, Alonso-Pena D. A new onychocryptosis classification and treatment plan. J Am Podiatr Med Assoc. Sep-Oct 2007;97(5):389-93. [Medline].

  2. Grassbaugh JA, Mosca VS. Congenital ingrown toenail of the hallux. J Pediatr Orthop. Dec 2007;27(8):886-9. [Medline].

  3. Lee JH, Kim SE, Park K, Son SJ. Congenital ingrown toenails successfully treated with simple plastic tube insertion. Int J Dermatol. Feb 2008;47(2):209-10. [Medline].

  4. Sarifakioglu E, Yilmaz AE, Gorpelioglu C. Nail alterations in 250 infant patients: a clinical study. J Eur Acad Dermatol Venereol. Jun 2008;22(6):741-4. [Medline].

  5. Luther J, Glesby MJ. Dermatologic adverse effects of antiretroviral therapy: recognition and management. Am J Clin Dermatol. 2007;8(4):221-33. [Medline].

  6. Shaikh FM, Jafri M, Giri SK, Keane R. Efficacy of wedge resection with phenolization in the treatment of ingrowing toenails. J Am Podiatr Med Assoc. Mar-Apr 2008;98(2):118-22. [Medline].

  7. Rounding C, Bloomfield S. Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev. Apr 18 2005;CD001541. [Medline].

  8. Bostanci S, Kocyigit P, Gurgey E. Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails. Dermatol Surg. Jun 2007;33(6):680-5. [Medline].

  9. Yang G, Yanchar NL, Lo AY, Jones SA. Treatment of ingrown toenails in the pediatric population. J Pediatr Surg. May 2008;43(5):931-5. [Medline].

  10. [Best Evidence] Bos AM, van Tilburg MW, van Sorge AA, Klinkenbijl JH. Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. Br J Surg. Mar 2007;94(3):292-6. [Medline].

  11. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. Feb 15 2009;79(4):303-8. [Medline].

  12. Czarnowski C, Ponka D, Rughani R, Geoffrion P. Toenail resection: minor surgery video series. Can Fam Physician. Nov 2008;54(11):1555. [Medline].

  13. Chapeskie H. Ingrown toenail or overgrown toe skin?: Alternative treatment for onychocryptosis. Can Fam Physician. Nov 2008;54(11):1561-2. [Medline].

  14. Aksoy B, Aksoy HM, Civas E, Oc B, Atakan N. Lateral foldplasty with or without partial matricectomy for the management of ingrown toenails. Dermatol Surg. Mar 2009;35(3):462-8. [Medline].

  15. Orenstein A, Goldan O, Weissman O, et al. A comparison between CO2 laser surgery with and without lateral fold vaporization for ingrowing toenails. J Cosmet Laser Ther. Jun 2007;9(2):97-100. [Medline].

  16. Ishibashi M, Tabata N, Suetake T, et al. A simple method to treat an ingrowing toenail with a shape-memory alloy device. J Dermatolog Treat. 2008;19(5):291-2. [Medline].

  17. Moriue T, Yoneda K, Moriue J, et al. A simple therapeutic strategy with super elastic wire for ingrown toenails. Dermatol Surg. Dec 2008;34(12):1729-32. [Medline].

  18. [Guideline] Gahagan S, Silverstein J. Prevention and treatment of type 2 diabetes mellitus in children, with special emphasis on American Indian and Alaska Native children. American Academy of Pediatrics Committee on Native American Child Health. Pediatrics. Oct 2003;112(4):e328. [Medline].

  19. Edlich RF, Winters KL, Britt LD. Bacterial diseases of the skin. J Long Term Eff Med Implants. 2005;15(5):499-510. [Medline].

  20. Gross RH. Foot pain in children. Pediatr Clin North Am. Dec 1986;33(6):1395-409. [Medline].

  21. Ilfeld FW. Ingrown toenail treated with cotton collodion insert. Foot Ankle. Apr 1991;11(5):312-3. [Medline].

  22. Information from your family doctor. Ingrown toenails. Am Fam Physician. Feb 15 2009;79(4):311-2. [Medline].

  23. Manusov EG, Lillegard WA, Raspa RF. Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot. Am Fam Physician. Aug 1996;54(2):592-606. [Medline].

  24. Noronha PA, Zubkov B. Nails and nail disorders in children and adults. Am Fam Physician. May 1 1997;55(6):2129-40. [Medline].

  25. Rich P. Nail disorders. Diagnosis and treatment of infectious, inflammatory, and neoplastic nail conditions. Med Clin North Am. Sep 1998;82(5):1171-83, vii. [Medline].

  26. Robbins JM. Recognizing, treating, and preventing common foot problems. Cleve Clin J Med. Jan 2000;67(1):45-7, 51-2, 55-6. [Medline].

  27. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. Mar 15 2001;63(6):1113-6. [Medline].

  28. Zuber TJ. Ingrown toenail removal. Am Fam Physician. Jun 15 2002;65(12):2547-52, 2554. [Medline].

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Further Reading

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Keywords

ingrown nails, acronyx, ingrown fingernail, ingrown toenail, onychocryptosis, paronychia, unguis incarnatus, unguis aduncus, sepsis, osteomyelitis, obesity, diagnosis, treatment

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Contributor Information and Disclosures

Author

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Coauthor(s)

Ann G Egland, MD, Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center
Ann G Egland, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Association of Military Surgeons of the US, Medical Society of Virginia, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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