Ingrown Toenail

The protocol for Ingrown Toenails:

Ingrown Toenail


Let’s break it down!

Ingrown toenails, also known as “Onychocryptosis” are all too common.  According to the 2012 National Foot Health Assessment, 18% of U.S. adults age 21 and older (40 million people) have experienced an ingrown toenail.  With as much time as soldiers spend on their feet, you can easily see why this protocol is included in our scope.

Ingrown toenails are often caused by weight-bearing (activities such as walking, running, etc.) in patients that have too much soft skin tissue on the sides of their nail. Weight-bearing causes this excessive amount of skin to bulge up along the sides of the nail.  Having tight-fitting shoes tends to exacerbate this problem.  The pressure on the skin around the nail results in the tissue being damaged, resulting in swelling, redness, and sometimes infection.

You ever noticed that the same people tend to get them over and over again?  Some of this can be explained by poor habits (trimming nails in a curved fashion, poor hygiene, etc.), but many cases are influenced by genetic predispositions for abnormally-shaped nail beds.  Don’t judge!

This is pretty self-explanatory.  Most patients with ingrown toenails are very aware of what’s wrong with their toe. It will classically be red, swollen, and painful. They’ll be able to feel their nail digging into their toe over time.  The “hyperkeratosis” refers to a thickening of the stratum corneum, which is the outermost layer of the skin. You’ll often see this on the side of the toe that’s affected most.

Image result for ingrown toenails





Who better to explain an ingrown toenail removal procedure than the Toe Bro himself?


Couple notes:

  • In the videos, he uses phenol at the end to cauterize the site and prevent regrowth.  Instead of phenol, the protocol utilizes silver nitrate sticks, but they can both work!


  • In the protocol, it states “use lidocaine w/o epinephrine“.  It used to be common practice to avoid using epinephrine on fingers and toes due to fears of gangrene from prior cases, but this myth has recently been debunked.  If all you have is lidocaine w/ epinephrine, it is safe to use this.


  • A good pro tip is to let the patient’s foot soak in warm water beforehand.  This helps facilitate an easy procedure.

Any time you perform a procedure that involves puncturing or cutting the skin, you should take precautions to prevent the onset of an infection.  Mupirocin (also known as Bactroban) is a prescription-grade antibiotic ointment that’s commonly used to prevent post-op infections.  If you don’t have Mupirocin, then you can use over-the-counter antibiotic ointments like bacitracin or Neosporin.

Image result for mupirocin






Also, you’ll want to give the patient appropriate pain management as well.  Eventually, the lidocaine you gave them for the procedure will wear off and the toe is going to feel the trauma you inflicted on it!  Tylenol and/or NSAIDs from the Pain Management protocol should do just fine.

It’s not routinely recommended to give oral antibiotics for an ingrown toenail, but if it looked grossly infected from the start or you anticipate that the soldier’s toe is going to fall victim to the nastiness of the tactical environment, then the antibiotics will help. Moxifloxacin and Azithromycin are both easy-to-take, broad-spectrum antibiotics that can cover for a variety of potential bugs.

Most cases of ingrown toenails are not serious issues. With treatment and proper follow-up, it is unlikely that the patient will encounter any complications. No evacuation should be needed. If the entire toenail is removed, it will grow back within 3-6 months. 



Good luck out there!




Brandon Simpson, PA-C
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