Ingrowing Toenail

An ingrowing toenail happens when the edge of the nail grows into the skin beside it, usually on the big toe. It causes pain, redness and swelling, and the toe can become infected. Mild cases often settle with salt-water soaks and roomy shoes. Persistent or recurrent cases are treated with a minor procedure under local anaesthetic.

The problem is common. It is most common in teenagers and usually affects the outer edge of the big toenail, although either edge of any nail can be involved.

What causes an ingrowing toenail?

• Incorrect nail cutting, particularly cutting the nail too short or rounding the corners
• Sports injury or other trauma to the toe
• Tight or narrow footwear that presses the skin against the nail edge
• Sweaty feet, which soften the skin and make it easier for the nail to dig in
• Nail shape: some people have naturally wide or curved nails

What are the signs of infection?

• Swelling and redness around the nail
• Pain and heat in the area
• Pus or discharge
• A bad odour

If you suspect an infection, arrange an appointment promptly. The NHS advises seeing a GP if you have a very high temperature or feel hot, cold or shivery, or if you have diabetes and an ingrowing toenail, because foot problems can be more serious in people with diabetes.

What can I do at home?

For a mild ingrowing toenail without signs of infection, the NHS recommends:

• Soaking the foot in warm, salty water to soften the skin and reduce the chance of infection
• Keeping the foot dry for the rest of the day
• Wearing wide, comfortable shoes or sandals
• Taking paracetamol or ibuprofen for pain
• Not picking at the toe or nail

To help prevent the problem returning, cut toenails straight across, not too short, and wear well-fitting shoes.

How is an ingrowing toenail treated?

Treatment depends on how severe the problem is, whether it is infected and whether it has happened before.

Antibiotics. If the toe is infected, a course of antibiotics, typically for one week, may be prescribed.

Partial or total nail removal. For persistent, infected or recurrent cases, the ingrowing edge of the nail, or occasionally the whole nail, is removed. Phenol may be applied to the nail bed to stop the edge growing back. The procedure is performed under local anaesthetic as a day case. Daily salt-water bathing of the toe is needed for three weeks afterwards.

The evidence supports this approach. A Cochrane review of 24 trials (Eekhof and colleagues) found that surgery is more effective than non-surgical treatment at preventing recurrence. In one trial of 117 people included in that review, the nail came back in 14% when phenol was added, compared with 41% without it. Simply pulling the nail out without treating the nail bed has a high chance of the problem returning.

Excision of the nail bed. For recurrent cases where the nail has already been removed, the root of the nail is cut out to prevent regrowth. This needs 3–5 days' rest at home and avoidance of high-impact activities for 3–4 weeks.

Subungual exostectomy. Occasionally a small bone spur under the nail (a subungual exostosis) pushes the nail up and causes the problem. This is confirmed with X-rays before surgery and can be removed surgically.

What is recovery like after nail surgery?

After partial or total nail removal:

• Day of procedure: go home directly, ideally by taxi, and rest for the remainder of the day
• Next day: return to non-manual work
• 0–3 weeks: daily salt-water soaks and redressing of the toe
• 2 weeks onwards: return to high-impact activities

Recovery after excision of the nail bed is slower, as described above. The Cochrane review found that dressings and antibiotics given routinely after surgery did not reduce infection, pain or healing time, so good wound care at home is what matters most.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Ingrown toenail. NHS. https://www.nhs.uk/conditions/ingrown-toenail/
2. Eekhof JA, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev. 2012;(4):CD001541. PMID: 22513901. https://pubmed.ncbi.nlm.nih.gov/22513901/
3. Corns and calluses. NHS. https://www.nhs.uk/conditions/corns-and-calluses/