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Clinical Summary

Ingrown toenail occurs from impingement and puncture of the medial or lateral nail fold epithelium by the nail plate, allowing growth into the dermis. Granulation tissue causes sharp pain, erythema, and further swelling. The granulation tissue may become epithelialized, preventing elevation of the nail above the nail groove. There is often secondary bacterial or fungal infection. Risk factors include cutting nails short, tightly fitting shoes, and trauma. Differential includes paronychia, felon, and tumor.

Management and Disposition

Elevation of the nail out of the fold and placement of gauze under it to prevent contact, in conjunction with warm soaks, is the initial therapy. If infected, removal of part of the nail and sometimes destruction of the involved nail matrix is necessary. The nail section is removed followed by paronychial fold packing with petroleum gauze or other nonadherent dressing. Consider follow-up with a podiatrist until growth of the nail plate is complete. The destruction of the nail matrix is required for recurrent infected ingrown toenails and is not part of routine emergency care.


  1. Ingrown toenail is most common in the great toe.

  2. Use of antibiotics is not a substitute for surgical excision.

FIGURE 12.16

Ingrown Toenail and Removal. Typical appearance including granulation tissue and erythema. After digital block, a hemostat is paced under the nail in the affected area to the matrix. The portion of the nail under the cuticle (wing) is flipped out and the nail is cut. The use of silver nitrate is optional. Nonadherent gauze or bacitracin should be used before bandaging. (Photo contributor: Lawrence B. Stack, MD.)

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