By Matthew J. Streitz, MD, San Antonio Uniformed Services Health Education Consortium

An ingrown toenail is incurvation or impingement of a nail border into its adjacent nail fold.

(See also Ingrown Toenail.)

Indications for Treating an Ingrown Toenail

Inflammation and/or infection around the ingrown toenail

Confirm that the periungual soft tissues (nail fold) are actually extending over the lateral part of the toenail. (Otherwise, consider alternative diagnoses such as trauma, gout, paronychia, or cellulitis.)

Contraindications to Treating an Ingrown Toenail

None

Complications of Treating an Ingrown Toenail

Nail fold hyperkeratosis, edema, or erythema

Infection

Nail regrowth

Inclusion cyst

Equipment for Treating an Ingrown Toenail

Cleansing solution, such as povidone-iodine or chlorhexidine

21- and 25-gauge needles

10-mL syringe

Local anesthetic, such as 1% lidocaine

Small rubber tourniquet

Elastic or gauze wrapping small enough to surround the toe

English anvil nail splitter, sharp-pointed scissors, or #11 scalpel

Forceps or hemostats

Wound closure strips, 2- to 3-mm diameter surgical drain cut open lengthwise, or a cotton pledget

Silver nitrate sticks, 1% phenol solution, or 10% sodium hydroxide solution

Antibiotic ointment without neomycin

Nonocclusive dressing

Sterile or nonsterile gloves

Positioning for Treating an Ingrown Toenail

Usually with the patient lying supine or sitting and the affected leg straight and well-supported

Step-by-Step Description of Treating an Ingrown Toenail

Several procedures can be done. Some involve only separating and isolating the nail fold from the nail (splinting the nail). Others involve removing part of the nail, either the lateral margin, or a spike-like segment of nail (spicule) growing adjacent to the lateral margin; spicules can develop as a complication of treatment or spontaneously. Sometimes, nail fold tissue is removed. Removal of the entire nail is no longer considered beneficial.

For all procedures

Cleanse the site with povidone-iodine or chlorhexidine solution.

Do a digital block to fully anesthetize the toe.

Apply a tourniquet at the base of the toe to control bleeding.

Determine extent of treatment based on degree of local soft-tissue inflammation or infection.

If inflammation is minimal, consider splinting the nail or removing only a nail spicule.

If inflammation is more extensive or for infection (particularly chronic) or severe pain, remove part of the nail.

To splint the nail

Elevate the lateral border of the nail with forceps or a hemostat.

Insert a cotton pledget (for mild inflammation), wound closure strip (for moderate inflammation), or 1-cm long strip from a 2- to 3-mm diameter surgical drain under the lateral nail edge.

Insert wound closure strips and surgical drain material, obliquely under the corner of the nail with a to-and-fro sawing motion until the corner is sufficiently elevated and is under the entire length of the nail.

Secure a tape closure around the toe.

To remove a nail spicule

If necessary, elevate the nail spicule with forceps or a hemostat.

Use the nail splitter or sharp-pointed scissors to cut longitudinally between the spicule and the nail plate continuing through the origin of the spicule, about ⅓ to ½ the way under the cuticle to the base of the nail.

Twist the nail spicule from the nail bed with a forceps or hemostat.

Remove any debris from the nail fold.

Control bleeding using silver nitrate.

If an abscess is present, drain all pus, irrigate any cavity, and dress the toe.

To remove all or part of the main part of the toenail

Use the nail splitter or sharp-pointed scissors to elevate the lateral 3 to 4 mm of the affected margin of the nail from the nail bed. Advance the splitter or point of the scissors parallel to the nail bed and go all the way to the proximal nail fold (cuticle).

Cut the nail lengthwise to separate the elevated segment, being sure to also cut the portion of nail under the cuticle.

Grab the segment of nail with forceps or a hemostat back close to the root and twist the segment root toward the rest of the nail, eventually freeing it from the nail fold and cuticle.

Gently retract the nail fold and cleanse the dermis or epidermis of any hidden debris. Apply a silver nitrate stick to control any bleeding.

Consider applying silver nitrate to the exposed nail bed and granulation tissue for 2 minutes because this tends to prevent nail regrowth.

If available, consider applying 10% sodium hydroxide (for 1 to 2 minutes) or 1% phenol solution on cotton-tipped applicators (3 applications, each about 30 seconds, or a single 5-minute application) to the exposed nail bed to permanently inhibit nail regrowth.

Aftercare for Treating an Ingrown Toenail

Dress the area with antibiotic ointment and a nonadherent dressing.

For splinted nails, have the patient wash the wound daily and reapply dressing as needed. Remove the splint when the inflammation has resolved and the nail no longer impinges on periungual tissue.

If part of the nail or a spicule has been removed, instruct the patient to soak the toe in warm water 2 or 3 times a day, redress it, and avoid harsh chemicals.

Reinspect the toe in 2 to 3 days for signs of infection, possibly earlier for patients at high risk (eg, those with diabetes, neuropathy, and/or peripheral vascular disease).

If the problem has not resolved, refer for definitive podiatric care.

Instruct patients to wear less constricting shoes and to trim the nail straight across.

Warnings and Common Errors When Treating an Ingrown Toenail

Be sure to cut all the way to the base of the nail so that no nail is left behind under the cuticle; failure to do so can allow spicule formation and recurrent inflammation.

Be sure to use a tourniquet; otherwise, bleeding may obscure the field.

Look for osteomyelitis in patients with recurrent ingrown toenails, circulatory dysfunction, neuropathy, and/or diabetes.

Tips and Tricks for Treating an Ingrown Toenail

If a nail splitter is not available, use a sharp-pointed scissors but maintain upward pressure while cutting the nail to minimize injury to the nail bed. Alternatively, use a disposable electric cautery device to cut the nail after softening it by soaking the toe in warm soapy water.

Ingrown Toenails

An ingrown toenail is when the corner of your toenail grows into your skin. It’s a common condition that happens frequently when you cut your toenails by tapering around the corners. Ingrown toenails usually aren’t serious and you can typically treat them at home. If you have diabetes or you think you have an infection, see a healthcare provider.

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Overview

Signs of an ingrown toenail infection include pain, redness, swelling and pus coming from your toe.

What is an ingrown toenail?

An ingrown toenail is a foot condition that develops when the corner of your toenail grows down into your skin. It usually affects your big toe, but it can affect any of your toes.

The condition often happens when people cut their toenails by rounding (tapering) the corner of their nails. If the toenail curves with the shape of your toe, it can grow into your skin. Ingrown toenails are common and don’t usually pose a health risk to healthy people.

Who is likely to have an ingrown toenail?

Anyone can get an ingrown toenail. People at a higher risk include adolescents, athletes and people who have:

Diabetes. Severe nerve damage in their leg or foot. Poor blood circulation. A nail infection (paronychia). How common are ingrown toenails?

Ingrown toenails are a common foot problem. Two out of every 10 people who see their healthcare provider for a foot issue go in for this condition.

Symptoms and Causes What causes ingrown toenails?

Ingrown toenails can have many causes. These may include:

Incorrectly cut toenails. If you cut your toenail too short or rounded, the nail may grow into your skin. Improperly fitting shoes. Tearing the corner of your nail. Toe trauma, such as banging your toe or getting stepped on. Your toe shape. For instance, if your nail is larger comparatively with your toe, or the surrounding tissue of the nail border naturally grows around your nail. What does an ingrown toenail look like?

An ingrown toenail grows into the skin around your nail bed. You may see redness and swelling around that area of your toe.

What are the symptoms of an infected ingrown toenail?

A mild ingrown toenail can feel hard and swollen. If the nail grows into your skin, or the skin grows over your nail edge, bacteria can enter. The nail may become infected. Infected ingrown toenail symptoms may include:

Liquid or pus coming out of your toe. Pain. Redness or darkening of the area. Swelling. Toe feeling warm or hot. What are the complications of ingrown toenails?

This foot condition usually doesn’t cause any complications in healthy people. You may develop an infection around your nail or scarring of your nail fold. In rare, chronic cases, an ingrown toenail infection can spread through your toe and into your bone.

Diagnosis and Tests How is an ingrown toenail diagnosed?

You can often diagnose the condition yourself, based on your symptoms and how your toe looks and feels.

Your healthcare provider (which may be your regular provider or a foot specialist called a podiatrist) will likely diagnose an ingrown toenail by inspecting it. They’ll examine the skin at the edge of your nail. They’ll diagnose you with this foot condition if the skin is:

Growing over your nail. Swollen, tender, warm and red or darker in color. Painful to light touch. Looks different than your other toes. What tests might I have for an ingrown toenail?

You typically don’t need any tests or X-rays to diagnose an ingrown toenail. In rare cases, when your toenail is severely infected, your healthcare provider might take a sample of the discharge or nail itself. They’ll run a bacteria culture test or sometimes a fungal culture to identify what’s causing the infection. You may need X-rays for more serious infections.

Management and Treatment Ingrown toenail self-care

Ingrown toenail home treatment includes several simple steps. These steps can help manage the infection and prevent further ingrown toenail pain.

Soak your foot in warm water mixed with Epsom salt or soapy, sudsy water twice daily. Keep your foot dry the rest of the time. Gently lift the edge of your nail. Place a small piece of cotton between the nail and your skin. You can also use dental floss under the ingrown toenail. Change the cotton or floss every day. This will help your nail grow above the edge of your skin. Use an antibiotic cream and a bandage. Wear roomy shoes or sandals. Use pain relievers such as ibuprofen or acetaminophen, if needed. How to remove an ingrown toenail

If you have signs of infection or a severe ingrown toenail, don’t attempt to cut it yourself. If you cut the nail, the condition may get worse. If symptoms aren’t getting better with home remedies for an ingrown toenail, see a healthcare provider.

Do I need a healthcare provider to treat an ingrown toenail?

If your symptoms haven’t improved within a few days, or the nail looks worse, call your healthcare provider.

You should also see your provider as soon as possible if you develop an ingrown toenail and you have:

Diabetes. Severe nerve damage. Poor blood circulation. A nail infection. How to fix an ingrown toenail

Most of the time, healthcare providers can treat mild ingrown toenails using the same techniques you would at home. But they use sterile and more professional instrumentation. This foot condition usually heals without surgery.

In severe cases, your healthcare provider may need to remove part of your nail surgically through a procedure called nail avulsion. Ingrown toenail surgery keeps the edge of your nail from growing inward and cutting into your skin.

During a partial or complete nail avulsion, your provider will inject a numbing medicine (anesthetic) into your toe. Then, they’ll cut away part or all of your toenail. It can take a few months for your nail to regrow. If the condition keeps occurring, your provider can perform permanent ingrown toenail removal with the assistance of a chemical to kill the nail root.

Prevention How to prevent ingrown toenails

You can take these steps to prevent an ingrown toenail:

Soak your nails in warm water before cutting them. Or cut your nails after a shower or bath. Clean your nail trimmer before using it. Don’t tear or rip your nails. Trim your toenails across the top. Don’t round the corners. Wear shoes that fit correctly. They shouldn’t be too loose or too tight around your toes. Avoid repetitive trauma to the sides of your nails. If you have diabetes, follow all foot care recommendations from your healthcare provider. Don’t be hesitant about seeking medical help. Outlook / Prognosis What is the outlook for someone with an ingrown toenail?

Most of the time, this foot condition isn’t a serious health problem. Ingrown toenail treatment usually works. Your ingrown toenail won’t grow back if you practice good foot care.

You may need regular foot care exams if you have a condition that causes foot problems, such as nerve damage or diabetes.

Living With When should I see my healthcare provider about an ingrown toenail?

See your healthcare provider for an ingrown toenail if you have:

Diabetes with complications. Signs of an infection (pus or liquid drainage, extreme pain or redness). Poor circulation.

You should also see your provider if you’ve tried topical antibiotic ointment, soaking and self-care but your toe still hurts.

What should I ask my healthcare provider?

If you have an ingrown toenail, ask your provider:

Is the nail infected? How can I best treat it? Do I need surgery? How can I keep it from coming back? Do I need medication? How should I cut my nails to avoid this condition?

A note from Cleveland Clinic

An ingrown toenail is annoying and painful but very treatable. Often, soaking your nail will improve symptoms within a few days. If it doesn’t get better, see your healthcare provider. They’ll show you how to treat an ingrown toenail. To prevent this condition, wear roomy shoes and cut your nails straight across, rather than tapering them to the shape of your toe.