Management of Ingrown Toenail in High-Risk Diabetic Patients

Immediate Risk Assessment

Uncontrolled diabetes significantly increases infection risk and impairs wound healing in patients with ingrown toenails, according to the American Diabetes Association 1, 2
Advanced chronic kidney disease further compromises immune function and healing capacity in diabetic patients with ingrown toenails, as stated by the European Society of Cardiology 3
Mobility impairment suggests possible peripheral neuropathy and/or peripheral arterial disease, both critical risk factors for poor outcomes in diabetic patients with ingrown toenails, as noted by the Infectious Diseases Society of America 1, 2
Ingrown toenails are significant predictors for diabetic foot ulcer development, which can lead to amputation, as reported by the British Association of Dermatologists 4

The patient needs immediate assessment for presence of infection, looking for erythema extending beyond the nail fold, purulent drainage, warmth, systemic signs, or any fluctuance suggesting abscess, as recommended by the Infectious Diseases Society of America 1, 2
Peripheral arterial disease should be checked through pedal pulses, ankle-brachial index, capillary refill, and skin temperature, as suggested by the American Heart Association 1, 2, 5, 6
Peripheral neuropathy should be assessed through protective sensation with monofilament testing, as stated by the American Diabetes Association 1, 2
Depth of tissue involvement should be determined to identify exposed bone or deep tissue infection, as recommended by the Infectious Diseases Society of America 1, 2

If no signs of infection are present, refer to podiatry/foot surgery within 1-2 weeks for definitive surgical management, as suggested by the American Podiatric Medical Association 2, 6
If signs of infection are present, this constitutes a diabetic foot infection requiring urgent multidisciplinary evaluation, as stated by the Infectious Diseases Society of America 1, 2, 7
Obtain wound cultures from deep tissue before starting antibiotics, as recommended by the Infectious Diseases Society of America 1, 2
Initiate empiric antibiotics immediately, covering Staphylococcus aureus, including MRSA if risk factors are present, as suggested by the American Diabetes Association 1, 2

Optimize glycemic control aggressively, targeting HbA1c <7% to reduce microvascular complications and improve wound healing, as recommended by the American Diabetes Association 5, 6, 3
Implement strict foot care protocols, including daily foot inspection, appropriate therapeutic footwear, skin cleansing, and topical moisturizing creams, as suggested by the American Podiatric Medical Association 5, 6
Assess and manage cardiovascular risk factors, including blood pressure control, statin therapy, and antiplatelet therapy, as recommended by the American Heart Association 5, 6, 3
Consider SGLT2 inhibitor therapy to reduce renal endpoints and cardiovascular events, as suggested by the European Society of Cardiology 3

Do not attempt conservative management as primary treatment in high-risk diabetic patients, as the risk of progression to serious infection or ulceration is too high, as stated by the Infectious Diseases Society of America 1, 2, 4
Do not delay referral, even for seemingly minor foot problems, as they can rapidly progress to limb-threatening infections, as recommended by the American Diabetes Association 1, 2
Do not prescribe antibiotics without obtaining cultures first if infection is present, as suggested by the Infectious Diseases Society of America 1, 2
Do not overlook assessment for peripheral arterial disease, as the combination of infection and ischemia dramatically worsens outcomes, as stated by the American Heart Association 1, 2, 5, 6