• An ingrown toenail is a common, often unpleasant condition frequently seen in the big toenail.
• Athletes commonly suffer from ingrown toenails.
• Improper shoe gear and toe injuries are frequently associated with ingrown toenails.
• It is not unusual for an ingrown toenail to recur unless treated appropriately.
• Conservative treatments include soaks, elevation, proper nail cutting, and good foot hygiene. Medical treatment is not always required. Oral antibiotics are sometimes required as a treatment if the infection is present. A health care professional can perform a minor toenail procedure if the problem is severe or recurrent.

An ingrown toenail (onychocryptosis) is caused by the pressure from the ingrowth of the nail edge into the skin of the toe. Once the edge of the nail breaks through the skin, it produces inflammation. Initially presented as a minor discomfort, it may progress into an infection in the adjacent skin (cellulitis) and/or become a reoccurring problem. Ingrow toenails most commonly affect the large (great) toes.

An imbalance between the size of the nail and the enlargement of the nail skin edge causes ingrown toenails. This condition can be exacerbated by improper trimming of the toenail, an inherited or hereditary condition, and improper shoe fitting. Injury by overly aggressive pedicures and nail picking are also common causes. Some people’s toenails naturally curl inward (known as pincer nails). These toenails can easily become painful. Adolescents and athletes perspire more often. This causes nails and skin to be soft. The thin nail can eventually split and pierce the softened skin.

There are a number of risk factors that may predispose a person to having an ingrown toenail. The following are some of the more common:

• Athletics, particularly stop and start sports such as tennis, soccer, and basketball
• Improper shoe gear that is either too small or too large
• Repetitive pressure or trauma to the feet
• Poor foot hygiene
• Abnormal gait and poor foot mechanics such as pronation
• Foot or toe deformities, such as bunions, hammertoes, and flat foot
• Congenital toenail deformity
• Abnormally long toes
• Obesity
• Diabetes
• Heart, kidney, and thyroid problems, which may cause foot and leg swelling
• Fungus infection of the nails (onychomycosis)
• Arthritis
• Bony or soft-tissue tumors of the toes
• Hyperhidrosis (excessive sweating of the feet)
• Edema of the lower extremities

Ingrown toenails most commonly occur in the large or “great toes.” Those great toes that are shorter than the second toes are even more prone to ingrown toenails. However, any of the toenails can be affected on either border or side.

The warm, moist environment of the feet can be a breeding ground for bacteria and fungi. These commonly include Staphylococcus, Pseudomonas, dermatophytes, Candida, and Trichophyton. When there is a break in the skin from the offending nail border, these organisms can invade the area and cause an infection. Treatment for these infections is essential to maintain healthy toenails and feet. The medical term for infected ingrown toenail is called paronychia. If not treated, the infected toenail can cause serious problems such as chronic pain and disfigurement, cellulitis, and bone infection.

Ingrown toenail symptoms and signs include redness, pain, and swelling. Sometimes there may be a clear yellowish drainage, or if it becomes infected, pus drainage. Young children may show signs of limping in order to avoid putting pressure at the ingrown toenail site. Occasionally, ingrown toenails resolve without treatment. A podiatrist should treat painful, persistent, and recurring ingrown toenails. If the ingrown toenail has been present for a long time, a very vascular tissue called granulation tissue may form that easily bleeds.

The diagnosis of an ingrown toenail is typically straightforward and does not require diagnostic labs or images. However, the signs and symptoms of ingrown toenails can vary quite dramatically, particularly if an infection develops. There may simply be some tenderness at the nail border when pressure is applied. There is typically an incurvation of the nail or a spike of the nail (spicule) pressing into the skin of the nail border. Associated redness and swelling localized to the nail also suggest the diagnosis of an ingrown toenail. When an infection is involved, there may be severe redness and swelling, drainage, pus, and malodor.

Making the proper diagnosis requires taking into account the medical history and all possible causative factors. If one is unsure, seek professional help. Some conditions such as tumors, foreign bodies, trauma, and fungal infection may appear to be an ingrown toenail to the untrained eye.

A persisting ingrown toenail can have serious consequences. A localized infection of the nail border (paronychia) can progress to a deeper soft-tissue infection (cellulitis), which can in turn progress to a bone infection (osteomyelitis). Complications can include scarring of the surrounding skin and nail borders (nail fold hypertrophy) as well as thickened, deformed (onychodystrophy) fungal toenails (onychomycosis). Sometimes, there is an enlargement of soft tissue at the nail fold that easily bleeds and drains.

The following home remedies may provide temporary relief.

• Lukewarm water foot soaks for 15-20 minutes with any one of the following options can be helpful: one part white vinegar to four parts water; 2 tablespoons Epsom salts per quart of water; or a dilute Clorox type bleach with 1/3 teaspoon of Clorox in 1 gallon of water. Gently massage the affected skin area downward while soaking.
• Elevate the foot and leg.
• Take oral anti-inflammatory medications.
• Apply antibacterial ointments on the affected side of the nail.
• Trim the toenail straight across the top without digging into the corners or leaving them too short.
• Carefully rolling back the overgrown skin at the affected nail border may allow one to slip a small piece of cotton or dental floss to lift the offending edge of the nail up from the skin.
• Wait for the nail to outgrow while attempting any one of the above methods.

If symptoms persist, medical treatment from a podiatrist is recommended.

People with diabetes or those who have a compromised immune system or poor circulation should promptly seek the care of a podiatrist/physician for ingrown toenail treatment even if the symptoms appear mild. If home remedies are not successful within a week or there is persistent pain and/or signs of infection, podiatric medical treatment is recommended. Symptoms and signs of infection can include

• swelling,
• redness,
• streaking (redness spreading from the toe to middle of the foot),
• pain,
• mal-odor, and
• drainage that may be yellow, green, or white and purulent (containing pus).

Although many types of doctors, including family physicians, pediatricians, urgent-care walk-in physicians, and dermatologists, can treat ingrown toenails, podiatrists (foot and ankle specialty doctors) are uniquely qualified among the medical professionals to treat this condition. A podiatrist’s office is also equipped with the necessary instruments required to perform ingrown toenail procedures.

There are various types of treatments, including self-care, soaking, avoidance of shoe pressure on the toenails, proper methods to trim the nails, and various surgical treatments. Sometimes antibiotics may be required.

Surgical treatments include the following: temporary resection and removal of the offending nail border or corner, avulsion (detachment) of the nail or offending nail border, or permanent elimination of the nail (matrixectomy) or offending nail border (partial matrixectomy). A matrixectomy is the destruction or removal of the cells where the nail grows from called the nail matrix. The nail matrix is at the base of the toenail under the skin. This procedure can be done surgically by dissection, chemically, or electrically by destroying part or all of the matrix cells. These procedures are commonly reserved for chronic or recurrent situations.

Simple resection and removal of the offending nail edge often do not require anesthesia. However, nail avulsion and matrixectomy do require local anesthesia. The anesthesia is injected directly into the toe and its effect lasts throughout the procedure. Because the anesthesia is administered locally, there is a minimal effect on driving or walking after the procedure.

The operated foot should be elevated for the remainder of the day. Typically, the dressings are removed the day following the procedure. Cleansing of the wound or soaks in Epsom salts and/or antimicrobial soap followed by application of an antibacterial cream and small bandage (Band-Aid) twice a day for one to two weeks can help to prevent infection. Open toe or loose-fitting, wide toe box shoes are recommended to avoid pressure to the toe while healing. Your doctor may want to see you return in a few weeks to ensure appropriate healing of the procedure site.

If a permanent resection of the nail was performed (matrixectomy), the nail will appear narrower by a few millimeters on the affected nail border. Unless a large portion of the nail was removed during the procedure, the overall appearance of nail does not change significantly. If the nail matrix is not removed or cauterized, then the nail should regrow to its original appearance and width.

Is surgery really necessary?

If conservative treatments fail, surgery to remove the offending nail border is recommended. If the condition is recurrent and/or chronic, a matrixectomy may be recommended. Both procedures (removal of offending nail and matrixectomy) are usually performed in your doctor or podiatrist’s office.

Complications from ingrown toenail surgeries are rare but can occur. Complications include infection after the procedure, prolong tenderness along procedure site, slow healing wound (especially in those with diabetes), and recurrence. You are more prone to post-surgery complications if you do not follow a proper instruction to care for the ingrown toenail. Fortunately, these complications are fairly easy to manage. If you are prone to infection, your doctor may prescribe oral antibiotics following the procedure.

Avoid shoes that are too small (putting pressure on the toenail) or too large (where the foot is moving back-and-forth inside the shoe). Improperly fitting footwear can cause trauma to the toenail. Sometimes the best shoes for symptomatic ingrown toenails are those without a closed toe box. Use proper methods of trimming the toenail with clean instruments, cut straight across toenails, and do not trim them too short. Wear corrective orthotic devices if you have faulty foot mechanics that result in excessive pressure at the nail fold.

• Do wear properly fitting shoes that allow you to wiggle your toes without having your foot slide around within.
• Do avoid repeated pressure and trauma to the toenails.
• Do wear sport-specific shoes.
• Do practice good foot hygiene.
• Do trim toenails straight across.

• Don’t cut down the corners of the toenails.
• Don’t trim toenails too short.
• Don’t wear improperly fitting shoes.
• Don’t avoid treatment by a professional if symptoms persist.
• Don’t do surgery on the toenail yourself.

The prognosis for an ingrown toenail is generally very good, particularly if professional treatment is engaged when the problem does not resolve itself after a week or so and risk factors are addressed.