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Textbook/Musculoskeletal medicine and orthopaedics/Ingrowing toenail and nail-fold infection/Rapid
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Ingrowing toenail and nail-fold infection

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2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Spreading nail-fold infection can threaten toe, foot and patient

Rapidly extending erythema, lymphangitis, fever, systemic illness, deep fluctuance, necrosis, severe pain, ulceration, poor perfusion or infection in diabetes and immune compromise may represent cellulitis, abscess, osteomyelitis or sepsis rather than a minor ingrowing nail.

Action: Assess ABCDE, glucose, perfusion, sensation and infection extent, remove constrictive footwear, elevate and mark spread, obtain deep samples and radiographs when indicated, start prompt severity-appropriate antibiotics, and involve surgical, diabetic-foot or vascular services urgently for abscess, deep infection, gangrene, critical ischaemia or systemic illness.

Synopsis

Grade ingrowing nail and acute paronychia, recognise spreading cellulitis, abscess, osteomyelitis and high-risk diabetic or ischaemic feet, deliver safe conservative care, and use drainage, partial nail avulsion, matrix treatment and antibiotics for defined indications.

  • Mild ingrowing nail causes edge tenderness and fold inflammation; moderate disease adds infection or drainage, while severe disease has hypertrophic granulation, chronic infection or marked tissue overgrowth.
  • First-line assessment is clinical: inspect both nail folds, identify the spicule, pus and granulation, examine toe pulp and joint, and document sensation, refill and pulses.
  • First-line mild management is a wide toe box, keeping the foot clean and dry, warm salt-water soaking, straight-across nail growth and gentle edge elevation only when circulation and sensation are normal.

Key red flags

Fever, tachycardia, spreading erythema, lymphangitis, confusion or hypotension requires urgent cellulitis and sepsis treatment rather than local nail care alone.

Investigation priorities

01
First-line nail, skin and neurovascular examinationFirst stepFirst line

Grade penetration, inflammation, abscess and spread and determine whether conservative or supervised procedural care is safe.

Management branches

First-line mildSeparate nail from fold safely

Tenderness and limited inflammation occur without pus, granulation, cellulitis, neuropathy or ischaemia.

  1. Change to a wide toe box, reduce repetitive pressure, use brief warm salt-water soaking and dry the fold carefully.
  2. Allow the nail to grow and trim straight across, avoiding corner digging, V cuts and unsterile instruments.

Key medicines

Flucloxacillin for spreading nail-fold cellulitisFor a stable suitable adult with spreading non-purulent cellulitis, give flucloxacillin 500 mg to 1 g orally four times daily for 5 to 7 days, reviewing response within 2 to 3 days and using local microbiology guidance.
Clarithromycin when penicillin is unsuitableWhen a non-pregnant adult has penicillin allergy and oral treatment is appropriate, give clarithromycin 500 mg orally twice daily for 5 to 7 days under NICE cellulitis guidance and review early.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom