Ingrown Toenail in Australia: Symptoms, Causes & Treatment | aihealz
Podiatrymild
Ingrown Toenail.Care & specialists in Australia
In Australia, ingrown Toenail is managed by podiatrys. Ingrown toenail (onychocryptosis) is a common condition in which the lateral or distal edge of the nail penetrates the surrounding skin, triggering an inflammatory and often infective response in the nail fold. The great toe is involved in over 85% of cases.
Ingrown toenail (ICD-10: L60.0), formally onychocryptosis, is the painful penetration of the nail plate into the periungual soft tissue of the lateral or distal nail fold, with secondary inflammation, hypergranulation, and frequent bacterial superinfection. The hallux (great toe) is affected in over 85% of cases, reflecting the combination of weight-bearing, footwear pressure, and the relatively flat curvature of the great-toe nail plate. The disease is classified by the Heifetz/Mozena staging system into three stages: Stage I (mild inflammation, erythema, oedema, and pain without discharge or granulation); Stage II (acute infection with serous or purulent discharge and increasing pain); Stage III (chronic with exuberant granulation tissue, lateral nail fold hypertrophy, and recurrent infection). The pathology involves the nail plate cutting into the lateral fold epidermis, eliciting a foreign-body inflammatory response that can become a chronic ulcer with infected granulation tissue.
key facts
Prevalence
Annual primary-care consultation rate roughly 200-300 per 100,000 in high-income countries; lifetime prevalence above 20% by some surveys
Demographics
Male:female ratio approximately 1.2-1.5:1; over 85% involve the hallux (great toe)
Avg. age
Peak incidence age 14-25 years; second smaller peak in older adults with poor foot self-care
Global cases
Estimated 5-10 million primary care visits worldwide per year
Specialist
Podiatry
§ 02
How you might notice it
The key symptoms of Ingrown Toenail are: Sharp pain along the lateral edge of the great-toe nail, worsened by walking, running, and wearing closed-toe shoes., Redness and swelling of one or both lateral nail folds developing over days to weeks., Warmth and tenderness on light pressure of the affected nail fold., Serous, sero-purulent, or frankly purulent discharge from the nail edge in Stage II disease., Exuberant pink-red granulation tissue (proud flesh) growing over the nail edge in chronic Stage III disease., Foul odour from the affected nail fold when chronic infection is present., Bleeding when the nail edge is bumped or trimmed..
01Sharp pain along the lateral edge of the great-toe nail, worsened by walking, running, and wearing closed-toe shoes.
02Redness and swelling of one or both lateral nail folds developing over days to weeks.
03Warmth and tenderness on light pressure of the affected nail fold.
04Serous, sero-purulent, or frankly purulent discharge from the nail edge in Stage II disease.
05Exuberant pink-red granulation tissue (proud flesh) growing over the nail edge in chronic Stage III disease.
06
§ 03
How it’s diagnosed
diagnosis
Diagnosis is clinical. History and examination identify the affected nail fold, stage of disease, and complicating factors. Inspect both feet for redness, swelling, discharge, granulation tissue, and pincer nail deformity. Document the duration of symptoms, prior episodes and treatments, footwear, sports activity, and nail-care habits. Examine for cellulitis, abscess, and lymphangitis tracking up the foot. Check distal pulses (dorsalis pedis, posterior tibial) and monofilament sensation in patients over 50 or with diabetes; impaired vascular supply or neuropathy elevates infection risk and changes management. Bacterial swabs are not routinely required but help in immunocompromised patients or where there is failure of empirical antibiotics. Plain radiographs of the foot are indicated when deep infection is suspected, with exposed bone, drainage that probes to bone, or chronic non-healing wound — features that should prompt MRI to exclude osteomyelitis. Blood glucose, HbA1c, and a basic full blood count are warranted in patients with severe cellulitis or systemic features. Differential diagnoses include subungual exostosis, glomus tumour, melanoma (especially subungual melanoma in older adults), and herpetic whitlow. New chronic granulation tissue in an older adult warrants biopsy to exclude amelanotic melanoma or squamous-cell carcinoma. Heifetz/Mozena staging guides treatment choice from conservative care to definitive surgery.
Key tests
01
Clinical inspection and Heifetz/Mozena stagingDetermines disease stage (I-III) and guides between conservative care and surgical intervention
02
Foot vascular and neurological assessmentIdentifies peripheral vascular disease, neuropathy, and infection risk before procedural treatment
03
Bacterial swab and cultureIdentifies the causative organism (Staphylococcus aureus, Streptococcus, Pseudomonas, anaerobes) when empirical therapy fails or in immunocompromised patients
§ 04
Treatment & cost
medical treatments
✓Warm salt-water soaks and cotton-wisp packing
✓Oral antibiotics (flucloxacillin or cephalexin 500 mg QID for 7 days)
✓Topical corticosteroid for granulation tissue
✓Silver nitrate cautery of granulation tissue
surgical options
Partial nail avulsion with chemical matricectomy (phenolisation)Recurrence rate 4-9% at 1 year versus over 30% with simple avulsion (Cochrane review, Eekhof 2012); preserved nail cosmesis in over 90%
Winograd partial matricectomy (surgical excision of the matrix)Recurrence 5-15%; slightly more post-operative pain than phenolisation but no risk of chemical burn
Vandenbos procedure (lateral nail fold soft-tissue excision)Recurrence under 5% in published case series; preserves full nail aesthetics
Total nail avulsion with full matricectomy (Zadik procedure)Recurrence under 5%; cosmetic outcome inferior to partial procedures
§ 05
Causes & risk factors
known causes
Improper nail-trimming technique
Curving the corners of the toenail or trimming the nail too short leaves a sharp lateral spike that catches the surrounding skin as the nail grows forward. The single most common modifiable cause across all ages.
Tight or pointed footwear
Narrow toe-boxes, high heels, and football or running shoes compress the lateral nail folds against the nail plate. Sports involving repetitive forefoot loading (football, running, ballet) account for many adolescent cases.
Trauma to the nail or toe
Dropping objects, stubbing the toe, or repetitive microtrauma during running can shift the nail plate and split the lateral edge, allowing it to dig into adjacent soft tissue.
Excessive transverse nail curvature (pincer nail)
Some patients have congenitally curved or pincer-shaped nails that grow into the lateral fold. This anatomy underlies most paediatric and recurrent cases and requires definitive matricectomy or Vandenbos lateral fold reduction.
Hyperhidrosis and prolonged wet conditions
Sweaty feet soften the nail and surrounding skin, making penetration of the nail edge into the soft tissue more likely. Common in adolescents and athletes.
Obesity increases mechanical loading on the great toe. Diabetes contributes through neuropathy and microvascular disease. Retinoids (isotretinoin, acitretin) and epidermal growth factor receptor inhibitors (cetuximab, erlotinib) cause paronychia and pyogenic granuloma that mimic or precipitate ingrown toenails.
risk factors
Adolescence and young adulthood (14-25 years)
§ 06
Living with it
01Trim toenails straight across, level with the free edge of the toe; never round the corners.
02Wear shoes with a wide toe-box that allow the toes to spread; avoid pointed shoes and high heels for daily wear.
03Change socks at least daily and choose moisture-wicking fabrics during sport.
04Treat hyperhidrosis with topical aluminium chloride and breathable footwear.
05Inspect the feet weekly in patients with diabetes, peripheral vascular disease, or neuropathy; seek prompt help for any nail-edge inflammation.
06Avoid digging out the nail corner with sharp implements — the most common trigger for acute ingrowth.
recommended foods
•Balanced diet rich in protein, vitamin C, and zinc to support tissue repair
•Adequate hydration to support skin and nail health
•Whole grains, fruits, and vegetables for general wound-healing nutrition
§ 07
When to seek help
why see a podiatry
Most ingrown toenails can be managed in primary care or by a podiatrist. Refer to podiatry, dermatology, or general surgery for recurrent disease, Stage III with significant granulation, pincer nails, suspected osteomyelitis, suspicious pigmented or non-healing lesions (rule out melanoma), and patients with diabetes, peripheral vascular disease, or immunocompromise.
01Bacterial cellulitis spreading proximally into the foot — detect by spreading erythema, warmth, lymphangitis; treat promptly with oral or intravenous antibiotics.
02Subcutaneous abscess of the lateral fold requiring incision and drainage in addition to addressing the nail edge.
03Osteomyelitis of the distal phalanx, especially in diabetes — non-healing wound probing to bone, raised inflammatory markers, abnormal MRI.
04Recurrent ingrown toenail despite simple avulsion — definitive matricectomy is the recommended next step.
05Cosmetic nail dystrophy after over-aggressive matricectomy.
06Rare but serious: necrotising fasciitis or gangrene in immunocompromised or diabetic patients with delayed presentation.
Stage I (mild inflammation)Redness, tenderness, and mild oedema of the lateral nail fold with no discharge or granulation. Most cases resolve with conservative care: warm soaks, cotton wisp under the nail edge, and correct nail trimming.
Stage II (acute infection)Increasing pain, serous or purulent discharge from the lateral fold, surrounding cellulitis, and difficulty wearing shoes. Often warrants oral antibiotics and consideration of partial nail avulsion.
Stage III (chronic with granulation)Hypertrophic granulation tissue (proud flesh), chronic discharge, and lateral nail fold hypertrophy. Conservative care alone usually fails; partial nail avulsion with phenolisation or matricectomy is the procedure of choice.
Juvenile (pincer or congenital deformity)Excessive transverse curvature of the nail plate present from childhood, often bilateral, leading to recurrent ingrowth. Vandenbos procedure or definitive matricectomy may be required.
Diabetic or immunocompromised ingrown toenailHigher risk of cellulitis, deep tissue infection, osteomyelitis, and amputation. Requires aggressive treatment, vascular assessment, and multidisciplinary diabetic foot care.
Living with Ingrown Toenail
Timeline
Acute pain and redness improve within 2-4 days of starting conservative care or oral antibiotics. After partial nail avulsion with phenolisation, the wound oozes for 1-2 weeks and re-epithelialises by 3-4 weeks. Return to sedentary work within 1-3 days; return to running and contact sports by 2-4 weeks. Final cosmetic appearance is established by 3-6 months as the remaining nail grows forward.
Lifestyle
01Soak the affected foot in warm salt water 2-3 times daily during acute episodes.
02Wear open-toed or wide sandals during recovery from acute inflammation.
03Replace cotton wisps daily and keep the area dry between soaks.
04Use over-the-counter analgesics (paracetamol or ibuprofen) for short-term pain control.
05Avoid contact sports and prolonged running until the toe is pain-free.
06Schedule professional nail-cutting visits every 6-8 weeks if self-care is difficult (older adults, diabetes, arthritis).
Daily management
01Soak the foot in warm salt water 15-20 minutes twice daily during acute phases.
02Insert a fresh cotton wisp under the nail edge after each soak in Stage I disease.
Complementary approaches
Orthonyxia (nail bracing with stainless-steel wires or composite splints)Non-surgical method to gradually correct excessive transverse curvature of the nail plate. Brace is glued or hooked to the nail and adjusted over 2-6 months. Reasonable for adolescents who wish to avoid surgery, though long-term recurrence after brace removal is debated.
Gutter splint techniqueA small plastic tube split lengthwise is fitted over the offending nail edge, isolating it from the soft tissue while the nail grows out. Useful in Stage I-II disease and during pregnancy when surgery is best avoided.
Choosing a doctor
Choose a podiatrist or general practitioner trained in nail surgery with experience in phenolisation. Ask about their routine recurrence rate and whether they offer the Vandenbos procedure for selected patients. Diabetic patients should be reviewed by a multidisciplinary diabetic foot clinic where available.
An ingrown toenail occurs when the edge of the nail, usually the great toe, penetrates the surrounding skin, causing pain, redness, swelling, and sometimes infection. The great toe is involved in more than 85% of cases.
What causes an ingrown toenail?▾▴
Common causes include cutting the nail too short or curving the corners, tight or pointed shoes, sports trauma, sweaty feet, congenital pincer-shaped nails, and certain medicines (retinoids, EGFR inhibitors). Diabetes and neuropathy raise the risk of complicated infection.
How do I treat an ingrown toenail at home?▾▴
Soak the foot in warm salt water for 15-20 minutes 2-3 times daily, gently lift the nail edge with a small wisp of sterile cotton or unwaxed dental floss, keep the toe dry between soaks, and wear open-toed or wide shoes. Most Stage I cases resolve within 4-6 weeks.
When should I see a doctor?▾▴
See a clinician if pain is severe, the toe is discharging pus, redness spreads beyond the nail fold, fever develops, you have diabetes or neuropathy, or the problem keeps coming back. Diabetics with any toe infection should seek same-day review.
Do I need antibiotics for an ingrown toenail?▾▴
Antibiotics are needed when cellulitis (red, warm, spreading skin) or pus is present, but not for mild inflammation alone. Oral flucloxacillin or cephalexin for 7 days is first-line in non-allergic patients; clindamycin or doxycycline for penicillin allergy.
What is the best surgery for an ingrown toenail?▾▴
Partial nail avulsion with chemical matricectomy using 80-88% phenol is the procedure of choice for recurrent or Stage III disease. It has a recurrence rate of 4-9% compared with over 30% for simple avulsion alone (Cochrane review 2012).
How is the surgery done?▾▴
Under local digital block anaesthesia, a 3-4 mm strip of nail along the affected edge is removed. The exposed germinal matrix is treated with 80-88% phenol for 60-90 seconds (three applications) to prevent regrowth of that nail strip. The procedure takes 20-30 minutes in clinic.
How long does it take to heal after surgery?▾▴
Wound oozing settles within 1-2 weeks; full re-epithelialisation by 3-4 weeks. Return to sedentary work within 1-3 days and running or contact sports by 2-4 weeks. Final cosmetic appearance develops by 3-6 months as the remaining nail grows forward.
Will the nail look normal after partial avulsion?▾▴
Yes. Partial nail avulsion with phenolisation preserves over 90% of the nail width. The treated nail edge does not regrow, producing a slightly narrower but normal-appearing nail in over 90% of patients.
How do I prevent ingrown toenails?▾▴
Cut nails straight across, level with the free edge of the toe. Avoid rounding the corners. Wear wide-toe-box shoes and moisture-wicking socks. Treat sweaty feet with topical aluminium chloride and inspect the feet weekly if you have diabetes or neuropathy.
Can children get ingrown toenails?▾▴
Yes. Adolescents aged 14-25 years have the highest incidence. Pincer-shaped nails, rapid foot growth, ill-fitting shoes, and sports are common triggers. Conservative care often works; the Vandenbos procedure or phenolisation handles recurrent cases.
What is the Vandenbos procedure?▾▴
Vandenbos surgery removes excess lateral nail-fold soft tissue rather than the nail itself, allowing the nail to grow forward without ingrowth. It preserves full nail width and is particularly useful for adolescents with pincer nails. Recurrence rates are under 5% in published case series.
Is an ingrown toenail dangerous?▾▴
Most ingrown toenails are not dangerous and resolve with simple care. Complications include cellulitis, deep abscess, osteomyelitis, and rarely amputation in diabetes or peripheral vascular disease. Seek prompt medical advice for spreading redness, fever, or non-healing wounds.
Can ingrown toenails cause infection of the bone?▾▴
Yes, but uncommonly. Osteomyelitis of the distal phalanx can complicate untreated ingrown toenail, especially in diabetic patients. Suspect when a wound probes to bone, is non-healing, or when inflammatory markers remain elevated. MRI confirms the diagnosis.
Are there non-surgical alternatives?▾▴
Conservative care (warm soaks, cotton wisps, footwear changes) resolves 50-70% of Stage I cases. Orthonyxia (nail braces) and gutter splints are non-surgical options for selected patients. Recurrent or Stage III disease typically needs partial nail avulsion with matricectomy.
How much does ingrown toenail surgery cost?▾▴
Cost varies widely. In the US private setting, partial nail avulsion with phenolisation typically ranges from US$200-700. Many insurers and public health systems (NHS, Medicare) cover the procedure when there is recurrent or infected disease.
Can I cut out an ingrown toenail myself?▾▴
Self-surgery is not recommended. Cutting deep into the nail-fold often worsens the problem, increases infection risk, and produces sharp lateral spikes that perpetuate ingrowth. Use cotton-wisp packing for mild cases and seek professional care for recurrent or infected disease.
Is there a link between ingrown toenail and diabetes?▾▴
Yes. Diabetic patients have higher rates of complicated infection, cellulitis, and osteomyelitis. Neuropathy delays detection, and microvascular disease impairs healing. Integrated diabetic foot care, regular podiatry review, and prompt treatment of any nail-edge problem reduce complications.
Can ingrown toenails come back after surgery?▾▴
Recurrence after partial nail avulsion with phenolisation is 4-9% at 1 year. Recurrence after simple avulsion alone is over 30%. Risk is higher with persistent improper nail trimming, tight footwear, and pincer-nail deformity not addressed at the time of surgery.
Can pregnancy cause ingrown toenails?▾▴
Pregnancy can trigger or worsen ingrown toenails through weight gain, foot oedema, and tighter footwear. Conservative measures are preferred during pregnancy; if surgery is needed, partial nail avulsion under local anaesthesia is considered safe at any trimester.
Can melanoma look like an ingrown toenail?▾▴
Yes, subungual melanoma can mimic chronic ingrown toenail with granulation tissue and discharge. New pigmented streaks under the nail, periungual pigment (Hutchinson sign), or non-healing lesions in older adults warrant urgent biopsy to exclude melanoma.
Foul odour from the affected nail fold when chronic infection is present.
07Bleeding when the nail edge is bumped or trimmed.
08Reluctance to bear weight on the affected foot or limp in younger children.
09Recurrent episodes of inflammation and infection in the same nail edge over months to years.
early warning signs
•Mild tenderness along the lateral edge of the great-toe nail after trimming or new footwear
•Faint red line along the nail fold without obvious swelling
•Recurrent transient discomfort following sports or running
•Mild oedema visible only when comparing the affected with the unaffected side
•A tendency to dig out the corner of the nail to relieve discomfort
● emergency signs
•Spreading cellulitis with red streaking up the foot and ankle — early lymphangitis
•Fever above 38 °C with foot pain in a patient with ingrown toenail — possible deep infection or bacteraemia
•Necrotic, dusky, or black tissue at the nail fold — possible necrotising soft-tissue infection
•Severe foot pain out of proportion to clinical appearance — exclude compartment syndrome or necrotising infection
•Diabetic patient with ingrown toenail, neuropathy, and rest pain — risk of foot ulceration and osteomyelitis; refer same day
04
Plain radiograph of the footExcludes underlying osteomyelitis, exostosis, and foreign body when deep infection is suspected
05
MRI of the footDefinitive imaging for osteomyelitis when X-ray is negative but clinical suspicion remains, especially in diabetic patients
06
Blood glucose, HbA1c, full blood count, CRPDetects undiagnosed diabetes and quantifies systemic inflammation in severe or recurrent infection
Outlook
Outcome is excellent with appropriate treatment. Stage I disease resolves in 50-70% of cases with conservative care alone. Stage II disease typically settles with antibiotics plus address of the nail edge. Stage III and recurrent disease have recurrence rates of 4-9% after partial nail avulsion with phenolisation, versus over 30% with simple avulsion alone. Cosmetic outcomes after partial procedures are good in over 90%, with preservation of nail width and contour. Complications include post-procedure infection (under 5%), persistent paraesthesia (under 2%), and rare nail dystrophy. Recurrence is more likely in patients with pincer nail deformity, persistent tight footwear, and ongoing improper nail care. Diabetic patients with complicated infection face higher rates of cellulitis, osteomyelitis, and rarely amputation when treatment is delayed.
Men have slightly higher incidence (ratio 1.2-1.5:1), attributed to higher rates of contact sports, occupational footwear, and less frequent professional pedicures.
Improper nail trimmingmodifiable
Curving or rounding nail corners is the dominant modifiable cause. Cutting straight across with a small free edge prevents the lateral spike that initiates ingrowth.
Tight, pointed, or high-heeled footwearmodifiable
Shoes with narrow toe-boxes increase compressive forces on the nail folds 2-3 fold. Switching to wide toe-box footwear reduces recurrence after surgery.
Football, running, ballet, and martial arts cause repetitive microtrauma to the great toe. Ingrown toenails are among the top three soft-tissue complaints in adolescent athletes.
Hyperhidrosis (sweaty feet)modifiable
Maceration of periungual skin makes penetration of the nail edge easier. Topical aluminium chloride and moisture-wicking socks reduce risk.
Pincer or congenitally curved nailsgenetic
Excessive transverse nail curvature is partly heritable and predisposes to chronic and recurrent ingrowth. Vandenbos procedure or matricectomy gives definitive control.
Raise the risk of cellulitis, deep infection, osteomyelitis, and amputation. Aggressive treatment and multidisciplinary foot care are required.
•Vitamin D supplementation if deficient
foods to avoid
•Excess alcohol intake which impairs wound healing
•Smoking and nicotine which reduce microvascular healing
•Highly processed foods that worsen systemic inflammation
•Excess simple sugars in patients with diabetes — control HbA1c improves wound outcomes
choosing the right hospital
01Trained podiatry or general practice nail surgery service
02Access to phenol and digital block anaesthesia
03Multidisciplinary diabetic foot clinic
04Pathology service for biopsy of suspicious lesions
05Vascular and orthopaedic referral pathways for complicated infection
Essential facilities
Primary care nail surgery clinicsCommunity and hospital podiatry servicesDermatology day-case unitsDiabetic multidisciplinary foot clinicsPlastic and general surgery day-case lists
03Keep the toe dry between soaks; pat carefully and air-dry.
04Apply prescribed topical antiseptic or antibiotic ointment as directed.
05Wear open-toed or wide-toe-box shoes until inflammation settles.
06Inspect the foot daily for spreading redness, swelling, or new discharge.
Exercise
Stay active during conservative management — walking in open-toed shoes is encouraged. Avoid running, football, and contact sports until the toe is pain-free, usually within 2-4 weeks of conservative care or 1-2 weeks after partial nail avulsion. Resume sport gradually with well-fitted footwear; consider toe protection (silicone sleeves) during the first few weeks.