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.
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..
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.
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.
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.
Find specialists →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.
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.
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.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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