Ingrowing toenail and nail-fold infection — Rapid

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.
Do not cut a V in the nail, dig down the corner or perform bathroom surgery; these approaches leave a sharp spicule, injure the fold and increase recurrence or infection.
Drain an established nail-fold abscess and remove the penetrating nail edge; antibiotics are not routinely needed after adequate local treatment unless cellulitis, systemic illness or high-risk host features are present.
First-line definitive procedure for recurrent or moderate-to-severe lateral disease is partial nail avulsion with lateral matrix ablation, commonly phenol under a trained protocol, rather than routine total nail removal.
For spreading non-purulent cellulitis in a stable suitable adult, NICE first-choice flucloxacillin is 500 mg to 1 g orally four times daily for 5 to 7 days, with review if not improving within 2 to 3 days.
Diabetes, neuropathy, ulceration or poor perfusion requires supervised podiatry or surgical care; seek urgent diabetic-foot or vascular input for deep infection, gangrene or ischaemia.

Key red flags

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

Fluctuance, visible pus, severe throbbing or extension into the toe pulp suggests abscess requiring drainage and surgical assessment.

Chronic drainage, exposed or probeable bone, destructive radiographs or recurrent infection raises osteomyelitis and needs deep sampling and specialist care.

Diabetes, neuropathy, immune suppression, renal failure or peripheral arterial disease lowers the threshold for rapid foot-service review and supervised procedures.

Coolness, rest pain, discolouration, tissue loss or absent pulses requires vascular assessment before nail avulsion or chemical matrix treatment.

Investigation priorities

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.

Change to a wide toe box, reduce repetitive pressure, use brief warm salt-water soaking and dry the fold carefully.
Allow the nail to grow and trim straight across, avoiding corner digging, V cuts and unsterile instruments.
Use gentle cotton or floss elevation only when sensation and perfusion are normal and stop if inflammation increases.
Review promptly for pus, granulation, spreading redness, fever or failure to improve.

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.Drain abscess and remove the nail spicule rather than relying on antibiotics; avoid in serious penicillin allergy, review liver and renal function and interactions, and escalate diabetes, immune compromise or systemic illness.

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.Check QT prolongation, liver and renal function and interactions including statins and anticoagulants; use erythromycin in pregnancy when a macrolide is required and follow current local guidance.

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