Background

An ingrown toenail, or onychocryptosis, occurs when a side of the nail plate begins to burrow into the skin and soft tissue at its edges along the nail bed. The affected area of the toe can become quite painful, red (erythematous), tender and swollen. The most common toe affected is the big toe. There are many different causes of ingrown toenails. Some of the common causes are cutting the toenails incorrectly (rounded instead of straight across the nail), shoes that are too tight, abnormally shaped toenails and fungal infections.

Signs and Symptoms

The symptoms of an ingrown toenail include:

• Toe pain
• Redness (Erythema)
• Swelling (Edema)
• Discharge from the ingrown region - Ingrown toenails have an increased risk of bacterial infection

Evaluation

Ingrown toenails are diagnosed by a clinical exam with a physician. The skin will be swollen, firm, red and/or tender to touch. There may also be a small amount of discharge or pus that drains from the site of the ingrown nail. An x-ray of the toe can be obtained if there was preceding trauma to the area and to rule out other potential problems. X-rays or other imaging are not usually needed for diagnosis.

Treatment

Treatment options:

• Soaking the foot in warm, soapy water, or Epsom salts three to four times a day for 10-20 minutes. After each soaking, dry the toe and place a small piece of wet cotton under the nail near the corner of the ingrown nail. This helps lift the nail from the skin and allow it to grow properly. The cotton should be changed daily.
• During this process wear comfortable, loose-fitting shoes.
• Avoid using a sharp object, such as manicure scissors, to dig under the nail, as this could increase the risk of infection.
• You should seek medical attention if symptoms are not improving after 2-3 days of this treatment.
• Severe infections may require your doctor to place you on antibiotics and remove part of the nail with a procedure called a partial nail avulsion.
• Your physician will perform the partial nail avulsion by first injecting numbing medication into the toe. Scissors are then used to cut along the edge of the nail that is ingrown. The ingrown portion of the nail is then removed. After the procedure, you should continue with regular foot soaks as noted above. The toe should be covered with a bandage. You should also wear loose-fitting, comfortable shoes. The nail will regrow in two to four months.

Prevention

Ingrown toenails are a common problem, but the risk can be reduced with a few basic steps.

• Ensure that your shoes fit appropriately; shoes that fit too tightly can compress toes together and lead to ingrown nails.
• Trimming nails correctly can also decrease the risk. Nails should be cut straight across, not curved, and not too short.
• Picking or tearing at the corners of your toenails can also lead to an ingrown toenail.
• Patients with diabetes or other conditions that can affect vascular circulation should take extreme care when trimming their nails.

Return to Play

Typically, most patients can return to work or school the following day after the removal of the ingrown nail. Most athletes can begin a gradual return to play 10-14 days after the procedure, as long as the pain is well-controlled.

AMSSM Member Authors
Michael Israel, MD, CAQSM, Sean Parham

References
Daniel CR 3rd, Iorizzo M, Tosti A, Piraccini BM. Ingrown toenails. Cutis 2006; 78:407.
Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician 2009; 79:303.
Ingrown Toenails. Patient Education Center. http://www.patienteducationcenter. org/articles/ingrown-toenail/. Accessed January 22, 2017