Ingrown toenails and paronychia

shutterstock_149255009I see patients who come into the clinic for ingrown nails, most often toenails but even ingrown fingernails can bring people to the doctor.

Paronychia: an inflammation involving the lateral and proximal fingernail folds.  It can be acute (rapid onset) or chronic (long-standing).

Causes:  occupations where the hands are in the water frequently, nail biting, thumb sucking, overzealous manicuring and even diabetes can lead to fingernail infections.

Ingrown toenail:  The big toe is most commonly affected.  Signs and symptoms can include pain, swelling, drainage and granulation tissue.  It’s more common to get ingrown toenails from poor fitting shoes, toe trauma, excessive trimming of the lateral nail plate, or in patients who have a over-curvature of the nail which can be hereditary or acquired.

Acute nail infections are usually accompanied by redness, and pain at the sides of the nail, sometimes with a blister that can be filled with purulent material If the patient hasn’t been biting their nails, the infection is most often caused by Staphylococcus aureus or Steptococcus pyogenes or a combination of both.  Different bacteria are often present if the patient is a nail biter.

Chronic nail infections are often associated with eczema, however it can also be complicated by a Candida or yeast infection of the nails.

Diagnosis:  In the clinic we can usually tell that there is a nail infection by the appearance of the nail folds on examination.  If a purulent fluid collection is present, the diagnosis is even easier to make.

Treatment:  If the infection has come on rapidly (acute onset), the treatment usually involves warm compresses or soaks to the affected finger or toe for 20 minutes three times/day.  Antibiotics that are taken orally may be helpful in severe causes.  Topical antibiotics such as triple antibiotic ointment might be helpful after soaking the digit, but there isn’t a lot of research to support it.

If there is an abscess present, incision and drainage is usually helpful in addition to the above treatments.  We usually perform a digital block to numb the finger or toe for comfort before the surgery is performed.  Treatment with antibiotics is common and we usually use them for 5 days after a surgical drainage and for 7-10 days if there is no drainage.  The choice of the antibiotic depend on whether the patient has been biting the nails, and the patient’s history of drug allergies.  Possible treatment options include dicloxacillin, Keflex (no no MRSA in suspected) or Bactrim.  We may also add metronidazole or clindamycin to the regimen if the patient has been biting their nails.

For ingrown toenails that are mild, we may place a cotton wedge or dental floss underneath the lateral nail plate to relieve the pressure and doing the soaks in warm soapy water for 10-20 minutes 3x/day.  If the ingrown nail is severe however, we usually perform a partial nail removal after doing a digital block to relieve the discomfort.  Antibiotics may be prescribed after partial nail removal may be helpful, however evidence has not shown that antibiotics decrease the healing time.

Follow-up after 3-4 days to assess treatment.

Recurrent ingrown toenails:  May require treatment with permanent nail ablation surgery using both surgical excision plus phenol ablation (chemical matricectomy).  The keeps the toenail from returning.

Post-op care after toenail removal:  You should be able to put weight on both feet immediately after surgery, but walking will be uncomfortable.  Some mild bruising and bleeding is normal after foot surgery. We usually apply some antibiotic ointment and 4×4” gauze, tube gauze and paper tape.  After 24-48 hours, soak the affected toe in warm, soapy water and reapply antibiotic ointment and a clean bandage.  This should be done 3-4x/day for 1-2 weeks after the procedure.   Keep your foot and leg elevated while sitting or lying down and make sure your bandages are clean and dry at all times.  We ask patients not to wear shoes for 3 days and recommend antibiotics and anti-inflammatory medications for 10 days.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.


I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO



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