Medical Care:

Treatment options depend on the stage of ingrown toenails, medically known as onychocryptosis.

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 as described in Surgical Care. Chronic ingrown toenails may require matrix ablation.

Surgical Care:

Stage 3 ingrown nails require avulsion of the lateral border of the nail plate with sharp excision of the hypertrophic granulation tissue. If avulsion has been unsuccessful in the past, partial or total ablation of the nail plate chemically, surgically, or via laser may be indicated. Prepare the digit with Betadine or alcohol if the patient is iodine allergic. Perform a digital block with 2% lidocaine without epinephrine. 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 scissors blade 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.

Consultations:

Consult a podiatrist 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.

Follow-up with a primary care physician is indicated for any type of immunosuppression, including diabetes mellitus.

Diet: No dietary limitations are required.

Activity: Rest, keep the extremity elevated, soak the affected nail in warm water, and maintain limited weight bearing until healing has taken place.