Management of Ingrown Toenail with Concurrent Onychomycosis

Rationale for Proceeding with Surgery

• The International Working Group on the Diabetic Foot guidelines recommend treating ingrown toenails promptly to prevent ulceration and complications, regardless of fungal infection status 1
• Ingrown toenails with thickening and curvature require definitive surgical intervention regardless of fungal infection status, as recommended by the International Working Group on the Diabetic Foot guidelines 1

Fungal Treatment Considerations Around Surgery

• Mechanical debridement during surgery can remove fungal-laden tissue, as noted by the British Association of Dermatologists 2, 3
• Thickened nails with fungal infection (>2mm thickness) are resistant to antifungal therapy alone, according to the British Association of Dermatologists guidelines 3, 4

Optimal Management Algorithm

• The British Association of Dermatologists recommends confirming fungal infection with mycological testing (microscopy and culture) before commencing treatment 5, 6, 7
• Systemic antifungal therapy, such as terbinafine 250mg daily for 12 weeks, should be initiated perioperatively or immediately post-operatively for dermatophyte onychomycosis, as recommended by the British Association of Dermatologists 5, 6, 7

Critical Pitfalls to Avoid

• The International Working Group on the Diabetic Foot guidelines advise against delaying surgery to complete a 12-week antifungal course first, as this prolongs morbidity from the ingrown nail without evidence of benefit 1
• The British Association of Dermatologists recommends against relying on topical antifungals for thick, curved nails, as the nail plate acts as a barrier to drug penetration 5, 8

Post-Operative Considerations

• The British Association of Dermatologists recommends continuing antifungal therapy for the full 12-week course, even after surgical healing, to prevent recurrence of fungal infection 5, 6
• Addressing reinfection risk factors, such as discarding or decontaminating old footwear and treating concurrent tinea pedis, is crucial to preventing recurrence of fungal infection, as noted by the British Association of Dermatologists 2, 3, 4

Special Populations

• The International Working Group on the Diabetic Foot guidelines strongly recommend treating both ingrown toenails and fungal infections urgently in diabetic patients to prevent complications such as ulcers and osteomyelitis 1, 9
• In immunocompromised patients, the British Association of Dermatologists recommends preferring terbinafine or fluconazole over itraconazole due to drug interaction risks with antiretrovirals 2, 4