Management of Ingrown Toenails and Pre-Ulcerative Conditions

Conservative Management

The American Diabetes Association recommends conservative treatment for pre-ulcerative signs in diabetic patients, including abundant callus on the toe tip or thickened nails, before considering surgical intervention 1, 2
Professional foot care, including proper nail trimming and callus removal, should be provided by trained professionals to diabetic patients with pre-ulcerative signs 2, 3
Patient education on daily foot inspection, proper footwear, and avoiding chemical agents for self-treatment is crucial for diabetic patients with pre-ulcerative signs 3

Digital flexor tenotomy should be considered when conservative treatment fails in high-risk diabetic patients with hammertoes and either pre-ulcerative signs or distal toe ulcers, with a 0% ulcer occurrence rate in 58 patients over 11-31 months follow-up 1, 2
Recurrence rates of 0-20% have been reported in 231 patients treated for distal toe ulcers over 11-36 months 2, 4

Integrated foot care every 1-3 months, including professional nail treatment, education, and therapeutic footwear, can prevent ulcer development in diabetic patients with neuropathy or PAD 2, 5
Surgical procedures carry a 9.5% post-operative infection risk in diabetic neuropathy patients, requiring careful patient selection 4

The American Diabetes Association recommends prescribing extra-depth shoes with wide toe-box and soft uppers to accommodate the deformity and reduce pressure on bony prominences 6
Consider custom-made insoles or toe orthoses for patients with foot deformity or pre-ulcerative signs, as recommended by the American College of Foot and Ankle Surgeons 7, 6
Provide regular professional treatment for excess callus, nail changes, and pre-ulcerative lesions on the toe apex or distal part, with a frequency of every 1-3 months for high-risk patients, according to the American Podiatric Medical Association 6

The American College of Foot and Ankle Surgeons recommends digital flexor tenotomy as first-line surgical treatment for neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformity, with a healing rate of 92-100% in mean 21-40 days and low complication rates 8, 9
Digital flexor tenotomy can be performed in an outpatient setting without subsequent immobilization, with recurrence rates of 0-20% over 11-36 months follow-up 9
When conservative treatment fails in patients with hammertoes and pre-ulcerative signs or distal toe ulcers, surgical intervention is recommended, according to the American Academy of Orthopaedic Surgeons 7, 8