II. Epidemiology

  1. Unilateral in 80% of cases
  2. Usually affects hallux (great toe)

III. Risk Factors

  1. Improper nail cutting (nail incurves into nail fold)
  2. Poorly fitting shoes, especially if constrictive (callus forms in nail fold)
  3. Impaired nail self-care
  4. Obesity
  5. Hyperhidrosis
  6. Foot Trauma
  7. Altered gait
  8. Congenital disorders
    1. Pachyonychia congenita
    2. Trisomy 13
    3. Unna-Thost Syndrome
  9. Comorbid conditions
    1. Pityriasis
    2. Hyperthyroidism
    3. Diabetes Mellitus (Dystrophic Nails)
    4. Acromegaly

IV. Signs: Ingrown Toenail

  1. Stage 1 Ingrown Nail
    1. Erythema, trace edema and pain at lateral nail fold
  2. Stage 2 Ingrown Nail
    1. Increased pain and foul discharge from nail edge
    2. Signs of Bacterial Paronychia
  3. Stage 3 Ingrown Nail
    1. Most significant symptoms of Ingrown Nail
    2. Lateral nail fold hypertrophy and chronic granulation tissue

V. Management: Non-surgical (mild cases with minimal pain or erythema)

  1. Expect resolution over 2-12 weeks
  2. Warm soapy water soaks for 15-20 minutes nightly and
  3. Raise lateral nail margins
    1. Insert cotton-wisp or dental floss under nail at Ingrown Nail groove edge or
    2. Use intravenous drip tubing as an improvised gutter splint
      1. Split intravenous drip tubing lengthwise, so can be inserted over the nail edge
      2. Tape, glue (cyanoacrylate) or wound-closure strips in place
      3. Arai (2004) In J Dermatol 43(10):759-65 [PubMed]
  4. Adjunctive
    1. Apply Corticosteroid cream or ointment to the affected area three times daily for 2-14 days
    2. Apply topical antibiotic (bacitacin) and/or Corticosteroid to ingrown margin twice daily
  5. General measures
    1. Wear shoes with open toe or with wide toe box
    2. Manage Hyperhydrosis
    3. Treat Onychomycosis

VI. Management: Antibiotics

  1. Not routinely recommended
  2. Has been used when matrix destruction is performed but without good evidence
  3. Paronychia may be the only indication for systemic antibiotics

VII. Management: Surgical Nail Avulsion (moderate to severe pain, inflammation, purulent drainage)

VIII. Complications

  1. Bacterial Paronychia
    1. Treat Paronychia with antibiotics if present
  2. Onychogryposis
    1. Hypertrophic shape changes of nail

IX. Prevention

  1. Trim nail flat (not too short, not rounded, not V-Shaped)

X. References

  1. Mandracchia (July, 1998) Hospital Medicine, p. 36-43
  2. Peggs in Pfenninger (1994) Procedures, Mosby, p. 28-43
  3. Mayeaux (2019) Am Fam Physician 100(3): 158-64 [PubMed]
  4. Heidelbaugh (2009) Am Fam Physician 79(4): 303-12 [PubMed]
  5. Zuber (2002) Am Fam Physician 65(2):2547-58 [PubMed]

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Related Studies

Ontology: Nails, Ingrown (C0027343)

Definition (MSH) Excessive lateral nail growth into the nail fold. Because the lateral margin of the nail acts as a foreign body, inflammation and granulation may result. It is caused by improperly fitting shoes and by improper trimming of the nail.
Concepts Acquired Abnormality (T020)
MSH D009263
ICD9 703.0
ICD10 L60.0
SnomedCT 123244000, 400097005, 18026002, 201113002, 276457004, 156402003, 400200009
English Ingrown Nails, Nail, Ingrown, Nails, Ingrown, Ingrowing nail NOS, Ingrowing toe nail, ingrowing nail, ingrown toenail, ingrowing nail (diagnosis), ingrown nails (physical finding), ingrown toenail (diagnosis), nails ingrowing, ingrown nails, Ingrowing nails, Ingrown toe nail, ingrowing toenail (physical finding), ingrowing toenail, Nails, Ingrown [Disease/Finding], ingrown nail, ingrowing nails toe, Ingrown;toenail(s), ingrow toenail, ingrown nails toe, ingrowing toenails, toe ingrown nail, nails ingrown, ingrowing toe nail, ingrown toe nail, ingrown toenails, Ingrown nail, Ingrown Nail, Ingrown toenail (disorder), Ingrowing nail NOS (disorder), Ingrowing claw, Unguis incarnatus, Ingrown toenail, Embedded toenail, Ingrowing nail, Onychocryptosis, OC - Onychocryptosis, Onyxis, Unguis aduncus, Ingrowing toenail, IGTN - Ingrowing toenail, Ingrowing nail (disorder), Ingrowing toenail (disorder), ingrowing; nail, nail; ingrowing, onychocryptosis, unguis incarnatus, Ingrown toenail -RETIRED-, Ingrown Toenail, ingrown toenail(s)
Italian Unghia incarnita, Onicocriptosi, Unghia del piede incarnita, Unghie incarnite
Dutch ingegroeide teennagel, ingroeiende teennagel, ingroeiende nagels, onychocryptose, Unguis incarnatus, ingroeien; nagel, nagel; ingroeien, ingroeiende nagel, Ingegroeide nagel, Ingegroeide nagels, Nagel, ingegroeide, Nagels, ingegroeide
French Ongles incarnés, Onychocryptose, Ongle incarné
German Unguis incarnatus, einwachsender Zehennagel, eingewachsener Zehennagel, einwachsende Naegel, einwachsender Nagel, Nägel, eingewachsene
Portuguese Onicocriptose, Unhas encravadas, Unha do pé encravada, Unha encravada, Unhas Encravadas
Spanish Unas encarnadas, Uña encarnada en dedo del pie, Onicocriptosis, Uña de pie encarnada, onicocriptosis, unguis aduncus, onixis, uña encarnada de dedo de pie, onicocriptosis (trastorno), uña encarnada de dedo de pie - RETIRADO -, uña encarnada de dedo de pie - RETIRADO - (concepto no activo), uña encarnada, SAI, uña encarnada, SAI (trastorno), unguis incarnatus, uña de dedo del pie encarnada (trastorno), uña de dedo del pie encarnada, uña encarnada (trastorno), uña encarnada, Uña encarnada, Uñas Encarnadas
Japanese 刺爪, 嵌入爪, シソウ, カンニュウソウ, サシヅメ, カンニュウツメ
Swedish Nageltrång
Czech nehty zarostlé, Onychokryptóza, Zarůstající nehty, Zarůstající nehet na noze, Zarostlý nehet nohy, Zarůstající nehet
Finnish Sisäänkasvaneet kynnet
Korean 내향성 손[발]톱
Polish Paznokieć wrośnięty
Hungarian Benövő körmök, Benőtt lábujjköröm, Benövő lábujjköröm, Benövő köröm, Onychocryptosis
Norwegian Unguis incarnatus, Inngrodd negl, Nedgrodde negler, Inngrodde negler, Nedgrodd negl

Ontology: Ingrowing great toenail (C0406444)

Concepts Disease or Syndrome (T047)
SnomedCT 201108001
English Ingrowing great toenail, Ingrowing great toenail (disorder)
Spanish uña del dedo gordo encarnada (trastorno), uña del dedo gordo encarnada

Ontology: Ingrowing toenail (excluding great toe) (C0406445)

Concepts Disease or Syndrome (T047) , Acquired Abnormality (T020)
SnomedCT 201109009
English Ingrowing toenail excl great, Ingrowing toenail (excluding great toe), Ingrowing toenail (excluding great toe) (disorder)
Spanish uña de dedo del pie encarnada (excepto la del dedo gordo) (trastorno), uña de dedo del pie encarnada (excepto la del dedo gordo)