Ingrown Toenail Management

Ingrown toenail Opener.jpeg

This module describes two conservative and one surgical treatment option for ingrown toenails.


  1. Ingrown toenails


  1. Surgical management contraindicated in:

    • Peripheral vascular disease
    • Coagulopathy
  2. Use of phenol contraindicated in pregnancy

  3. Chemical matrixectomy contraindicated in:

    • Uncontrolled diabetes
    • Peripheral vascular disease


How do I explain this procedure?

“Your toenail has become ingrown, which means that the corner or side of the toenail is pressing and cutting into the skin beside it, causing pain and putting you at risk of getting an infection. I will try to release the ingrown part, and if that does not work I may need to cut it out.”

What can my patient expect?

“I will give you an injection for pain. If the ingrowing is not too severe, I will just put cotton or a small piece of plastic between the toenail and your skin to prevent it from progressing. If it’s severe or it keeps on happening, I will cut out a section of your toenail and destroy the part that makes the nail grow out there so that it won’t happen again. If I’ve cut away part of the nail, expect the wound to ooze a bit of clear fluid for a few weeks until it dries out.”

What is my patient’s role?

“Let me know if you have any allergies or a bleeding tendency, use blood thinners, or have any medical conditions. Fearing blood or needles is normal, but tell me if you have fainted from it. Once we’re done, you’ll have to change the dressing in two days, and keep checking for signs of infection, like increasing redness, heat, swelling and pus.”


Documentation

  1. Patient notes

Equipment

Conservative management:

Ingrown toenail Equipment Coservative

  1. Non-sterile gloves

  2. Alcohol-based hand rub

  3. IV giving set

  4. Cotton wool

  5. Alcohol swab

  6. Suture pack

    1. Dental syringe
    2. Scissors
  7. Lignocaine

  8. Dental needle


Surgical management:

Ingrown toenail Equipment Surgical

  1. Non-sterile &

  2. Alcohol-based hand rub

  3. Linen saver

  4. Tourniquet

  5. Sterile drapes

  6. Suture pack

  7. Alcohol swab

  8. Dental needle

  9. 80-88% phenol solution

  10. 10 ml syringe of normal saline

  11. Cotton-tipped applicator

  12. Paraffin-impregnated gauze (Jelonet), gauze, and a crêpe bandage


Position the patient reclining with the knee bent and the foot flat on the bed.

Ingrown toenail Site.jpeg


Conservative management

Follow medical asepsis with non-sterile gloves.

  1. Perform hand hygiene and don non-sterile gloves.

  2. Open the suture pack.

  3. Clean the skin with an alcohol swab and perform a digital block. Wait 5-10 minutes.

  4. Use one of the following techniques:

    • Create a wisp of cotton wool and wedge it under the corner of the ingrown nail. Use see-saw movements to advance it under the nailfold until it splints the entire lateral/medial edge of the nail away from the affected nail fold, OR
    • Gutter splint: cut a section of an IV giving set as long as the affected medial/lateral nail fold. Cut it open lengthways. Slip the long edge under the entire affected nail edge to separate it from the affected medial/lateral nail fold.

Surgical management

Follow medical asepsis with sterile gloves.

  1. Perform hand hygiene.

  2. Open the suture pack to create a sterile field. Pour skin disinfectant into the bowl. Use spare gauze to remove the dental syringe from the field.

  3. Don non-sterile gloves, clean the skin with an alcohol swab and perform a digital block. Wait 5-10 minutes.

  4. Don sterile gloves.

  5. Clean and drape the toe.

  6. Apply a tourniquet made of rubber tubing or a glove, around the base of the toe to reduce bleeding. Secure the tourniquet with forceps.

  7. Use a haemostat to separate the affected side of the nail plate from the nailbed and affected nail fold down to the cuticle. You can do this by placing the haemostat between the nail and the nail bed and between the cuticle and the nail fold and working it loose.

  8. Use scissors to

    a section of the nail plate (about 3-5 mm wide) in a straight line down to the cuticle. Extend the cut below the proximal nail fold to include the root of the nail. Do not cut the cuticle or skin of the nailfold.

  9. by rotating it with forceps, ensuring that you also remove the root.

  10. Use a haemostat to explore the proximal nail fold for retained nail fragments.

  11. Use phenol on a cotton-tipped applicator (or the back of the applicator) to

    the matrix under the nail fold with three applications of 30 seconds each.

  12. Rinse away phenol with a syringe of saline or a cotton wool bud soaked in saline.

  13. Remove the tourniquet.

  14. Dress with paraffin-impregnated gauze, dry gauze, and a bandage.

  15. Dispose of medical waste safely.

  16. Record completion of the procedure in patient notes.


My patient has returned with an infection.

Treat the patient with a course of oral antibiotics covering skin flora.

I don’t have phenol available.

Without ablation of the matrix, the ingrown toenail is likely to recur. You may use silver nitrate sticks, but warn the patient that it might cause tattooing of the area. Alternatively, an experienced provider may excise the matrix mechanically, although this is an inferior treatment to chemical ablation and requires cautery, an assistant, and should preferably be done in theatre.

My patient has returned with a recurring ingrown nail despite ablation of the matrix.

Refer this patient to surgery for more radical management.


  1. Minor bleeding

  2. Poor cosmetic outcome

  3. Local infection

  4. Nail regrowth


  1. Mayeaux EJ Jr, Carter C, Murphy TE. Ingrown Toenail Management. Am Fam Physician. 2019;100(3):158-164.

  2. Chabchoub I, Litaiem N. Ingrown Toenails. [Updated 2021 Jun 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546697/

  3. Streitz MJ. How To Treat an Ingrown Toenail. In: MSD Manual. 2020.

  4. Mash B. How to Remove an Ingrowing Toenail. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010:167.