An ingrown toenail occurs when a piece of the toenail goes into the side of the toe leading to an inflammatory reaction and infection. Sometimes, you can take care of an ingrown toenail on your own, while other times, it requires the attention of a medical professional. It is the most common toe condition encountered by general practice physicians and podiatrists — foot specialists. An ingrown toenail has two different medical names: onychocryptosis and unguis incarnatus.
Ingrown toenails occur when the corner or edge of the nail pierces the epidermis outer skin layer.
The body reacts with an inflammatory response, and sometimes an infection results.
Symptoms of an ingrown toenail include pain, redness, warmth, inflammation, swelling, and yellow discharge (pus).
Conservative treatments include soaking in soapy water, over-the-counter triple antibiotic creams or ointments, open-toe footwear, and lifting the part of the nail causing the ingrown toenail.
A medical provider can prescribe oral antibiotics and prescription antibiotic ointment (cream).
This article explores the reasons for an ingrown toenail and the treatment options available.
Anatomy of an ingrown toenail
Ingrown toenails are most likely to develop in the large toes but can occur in any toe. An ingrown toenail is shown above. In this image, the edge of the toenail plate pierces the skin’s out layer — the epidermis. The body treats the piercing nail plate as a foreign body, resulting in a foreign-body reaction and reddish hyperemia due to increased blood flow.
Hyperemia differs from reddish erythema, a type of hyperemia in an infected area. Erythema occurs after the breakage of the skin’s barrier, the microbiota — bacteria normally present on the skin — enter the deeper tissues, resulting in an infection.
Symptoms of an ingrown toenail
Symptoms of an ingrown toenail consist of the following:
- Pain and tenderness.
- Inflammation and swelling.
- Heat or warmth.
- Yellow discharge (pus).
- Difficulty walking.
- Pain while wearing closed-toe shoes.
Some of the most common causes of an ingrown nail are:
- Improper nail trimming. The image above shows how to cut your nails properly (on the left) and improperly (on the right). If you notice on the properly cut nails, they are growing past the soft tissues, while the improperly cut ones have the sides of the nails cut too short – they are not past the soft tissues. When these improperly cut nails grow, the sides can grow into the soft tissues, leading to a foreign-body reaction and infection.
- Wearing tight shoes. Many shoes crowd the toes, causing the toenails to grow aberrantly.
- Genetics. Some people are born with abnormal toenail shape or texture, while others develop them later.
- Trauma. Having something hit your toenail can cause it to grow abnormally.
- Toenail fungus. A fungal infection of the toenail (onychomycosis) causes a toenail to be yellow, raised, and with abnormal texture, leading to an ingrown toenail.
- Toe deformity. Having a deformity like a hammertoe can lead to an ingrown toenail.
- Other causes. Tight socks, increased sweating, and diabetes can all lead to an ingrown toenail.
Ingrown toenail: Diagnosis and treatment
It's not hard for a physician or even a non-medical person to diagnose an ingrown toenail, given the obvious symptoms. Treatment can be done by yourself (self-treatment) or a medical professional; sometimes, a surgical procedure may be needed.
Among the self-treatment options for an ingrown nail are soaking, topical antibiotic cream, footwear changes, and at-home procedures. It is best to soak the ingrown toenail in soapy water before trying home remedies.
Soak the nail in warm water with antibacterial soap for 10–15 minutes a few times daily.
Epsom salts have been known to help with infection. However, we are not sure how Epsom salt soaks kill the bacteria. Some people theorize that the sulfur in the Epsom salts directly kills bacteria, while others feel the Epsom salts help get the bacteria out of the wound and into the water where they die.
Once the infection has resolved, we know that Epsom salts lead to better nail growth by softening the rough skin around the nail and helping remove dead skin.
Topical antibiotic cream or ointment
Topical antibiotic cream or ointment can resolve the infection. Some references recommend creams, while others recommend ointments. Both work, so it's a matter of personal preference. We recommend the cream since it is less greasy. There are many over-the-counter triple antibiotic options available. Neosporin is the brand name of a type of triple antibiotic that contains three antibiotics: neomycin, polymyxin, and bacitracin.
Footwear and at-home procedures
Avoid wearing tight shoes. Until the infection resolves, it is recommended to wear open-toe shoes or sandals. It is essential to chose the footwear that suits you best.
Additionally, there are a few at-home procedures that can help with an ingrown toenail. For example, a piece of dental floss can be used to lift the aberrant piece of nail that is causing the ingrown toenail, as shown in the image below. This may allow the ingrown piece to grow past the soft tissues and be trimmed with routine trimming instead of growing into the side nail.
Another way to treat it at home is to lift the ingrown piece with sterile forceps or tweezers. Then place a piece of cotton underneath (shown in the image below) the nail piece causing the ingrown toenail. Hopefully, this will allow the ingrown piece to grow past the soft tissues and be trimmed with routine trimming.
Medical treatment options
There are a few medical treatments offered by healthcare professionals.
- Antibiotics. If the infection has spread past the toe, a physician can prescribe antibiotics to be taken orally or by intramuscular injection. If the infection has spread to the foot and ankle, intravenous (IV) antibiotics are usually needed.
Topical antibiotics. Mupirocin (Bactroban) is a topical cream or ointment only available through a physician's prescription. Like the over-the-counter topicals, it can be applied directly to the infected toenail. It is believed to be stronger than other antibiotic topicals like Neosporin. In addition, Mupirocin tends to have deeper penetration of the wound.
In some cases, a surgical procedure is required. This is an office procedure that does not require a visit to the hospital. A numbing agent — usually xylocaine — is used in what's called a digital nerve block, where the agent is injected on each side of the infected toe. This is where the sensory nerves run, and a block at these two areas completely numbs the toe. Once the medicine starts working, you will feel a burning sensation, but nothing terrible — it just depends on your tolerance.
Once the toe is numb, the usual procedure is to remove the ingrown piece and then a few millimeters of the normal nail from the end of the nail to the base. Figure #5 shows a toenail after this procedure. In some cases, especially with repeated ingrown toenails at the same location, the nail bed under the partially removed nail is chemically treated so no new nail will grow. It's up to you and your medical provider, but chemically treating the nail bed is usually a good idea if you get an ingrown toenail. If it happened once, it is likely to recur.
Ingrown toenails can be a painful and limiting condition. However, there are ways to treat it by yourself and other ways by a medical professional.
- Stat Pearls. Ingrown toenail.
- Baylor Medical Center Proceedings. Ingrown toenails (unguis incarnatus): nail braces/bracing treatment.