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Antibiotics for Ingrown toenails

Discussion in 'General Issues and Discussion Forum' started by jos, Feb 21, 2009.

  1. jos

    jos Active Member

    Members do not see these Ads. Sign Up.
    Can anyone tell me which antibiotics are effective in dealing with a simple Staph infected ingrown toenail? I find GPs medicate with a wide variety. Is amoxycillin the drug of choice?
  2. Brummy Pod

    Brummy Pod Active Member

    According to my antibiotics update course that I did, Flucloxacillin is THE first choice, dependant of course on medical history.
  3. Brummy & Jos,
    What if your patient is allergic to penicillins? Amoxicillin doesn't seem to work on skin problems, anyway. So it is basically useless for ingrown nails.
    I'm going out on a limb here saying that cephalexin is the best for ingrown nail.
    Removal of the spicule is of course necessary or no antibiotic can be counted on to kill the infection. On the other hand, antibiotics are usually not needed if the spicule is removed.

    Tony Jagger
  4. Brummy Pod

    Brummy Pod Active Member


    With regards to your post, "what if the patient is allergic to penicillins," 110% correct, which is why I deliberately put in my post, the words, "dependant on medical history." Noting down any allergies is part of the medical history questioanire, is it not? Meant in the nicest possible way (sorry but there is so much rudeness on some forums nowadays), what else did you think I meant /implied by "dependant on medical history."?

    Brummy Pod
  5. G Flanagan

    G Flanagan Active Member

    Hi Jos,

    I have to agree with brummy pod, you would initially start on Flucloxacillin 500mg qds. Don't go down the route of 250mg as that would be about as useful as treating the infection with acupuncture.

    If penicillin allergy is present, the initial drug of choice would be Erythromycin.

    Couple of things to consider are:-

    Does your patient actually need them, if you have a healthy young chap with a localised infection, once you have removed the offending nail, it is likely it would settle on its own. I tend to only request AB's if i have spreading cellulitis, or occasionally in patients with systemic pathology.

    Secondly, do you have a POM certificate, as Fluclox is covered by it, so you could start the initial therapy yourself.

    As always it will rely on your observations, obviously if the area isn't responding to initial therapy, alternative AB's may be required.

    Dr Jagger, here in the UK, the first line therapy in a minor infection like this is almost always Fluclox, cefalexin is usually reserved for further down the line to combat gram -ve bacteria also. It is more commonly used for UTI's. I appreciate what your saying in terms of its use in skin infections, because mistakenly a number of people think it is a broad spectrum AB, when in which case you would be looking at amoxycillin or co-amoxiclav.


  6. jos

    jos Active Member

    thanks for the replies!
    This post wasn"t in relation to a particular Pt, just observations over the past decade that GPs prescribe a wide variety of antibiotics (generally BEFORE i see the Pt). I was just wondering which is more specific/appropriate for skin infections.
    I have had a few over the years prescribed Keflex, which I always thought was for respiratory infections....??
  7. Tuckersm

    Tuckersm Well-Known Member

    From the Australian Therapeutic Guidelines (Antibiotics and Dermatology)

  8. cornmerchant

    cornmerchant Well-Known Member

    If we could only get the GPs to refer immediately to a podiatrist , the need for antibiotics would be reduced significantly. How many times do you see a patient that has had two or even three courses of AB and still the problem is there? It is because they do not understand the etiology of the IGTN and are not aware of the treatment available. I have never sent a patient for AB and removal of the offending nail spike has always resolved the problem.

  9. Adrian Misseri

    Adrian Misseri Active Member

    G'Day all,

    I rarely refer for antibiotics for my ingrown toenails, except for the heavily infected, cellulitis type infections. Removal of the nail spike, clearing of the area of debris, drain any purrulent exudate, irrigation with saline, and meticulos patinet self management with regards to daily bathing in saline and keeping the toe dressed with betadine and a good breathable dressing (i.e. cutiplast/hansaplast etc. not bandaids!) sees most of them resolve very quickly.

    Here in Victoria we can't prescribe any antibiotics anyway, so I try to avoid a second medical bill for my patinet by having to send them back to their GP. That being said, I make myself available to the patinet if circumstances with the toe change.

    Steven, where are we at really with this S4 debate at the moment? I'm waiting to get into it, have done the Advanced Pharmacology for Podiatrists through UniSA, as well as the 4 year degree at La Trobe Uni. Just curious.

    Cheers all!
  10. Tuckersm

    Tuckersm Well-Known Member

    Very close. The Health Minister should sign off on the formulary this month (but we were told that in December as well)
  11. efuller

    efuller MVP

    1: Arch Fam Med. 2000 Sep-Oct;9(9):930-2. Links
    Are antibiotics necessary in the treatment of locally infected ingrown toenails?Reyzelman AM, Trombello KA, Vayser DJ, Armstrong DG, Harkless LB.
    Ankle and Foot Clinic, 1114 Broadway St, Longview, WA 98665, USA.

    CONTEXT: A wide variety of generalists and specialists treat locally infected ingrown toenails, with perhaps the most common treatment regimen including resection of the nail border coupled with oral antibiotics. OBJECTIVE: To determine whether oral antibiotic therapy is beneficial as an adjunct to the phenol chemical matrixectomy in the treatment of infected ingrown toenails. DESIGN: We prospectively enrolled healthy patients with infected ingrown toenails. Each patient was randomly assigned to 1 of 3 groups that received either 1 week of antibiotics and a chemical matrixectomy simultaneously (group 1), antibiotics for 1 week and then a matrixectomy (group 2), or a matrixectomy alone (group 3). SETTING: Institutional ambulatory outpatient clinic. PATIENTS: Fifty-four healthy patients with infected ingrown toenails were studied. Patients with immunocompromised states, peripheral vascular disease, or cellulitis proximal to the hallux interphalangeal joint were excluded. Groups were age matched for comparison. RESULTS: Mean healing times for groups 1, 2, and 3 were 1.9, 2.3, and 2.0 weeks, respectively. Subjects receiving antibiotics and a simultaneous chemical matrixectomy (group 1) healed significantly sooner than those receiving a 1-week course of antibiotics followed by a matrixectomy (group 2). There was not a significant difference in healing time between those that received a chemical matrixectomy alone (group 3) and those that received a matrixectomy coupled with a course of oral antibiotics (group 1). CONCLUSION: The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity.

    PMID: 11031403 [PubMed - indexed for MEDLINE]

  12. :good::drinks

    I HAVE sent patients for ABs but only where
    As George nicely puts it.

    Lets face it, if there is a damn great hole in the foot you could blast it with vancomycin if you were that way inclined, it will just re infect when the patient has a shower and everything they wash off their bodies ends up sloshing around their feet!

  13. Johnpod

    Johnpod Active Member

    Have you any evidence to support that statement, Robert?

    Or is this from your experience?
  14. NewsBot

    NewsBot The Admin that posts the news.

    Algorithm for the management of antibiotic prophylaxis in onychocryptosis surgery.
    Córdoba-Fernández A, Ruiz-Garrido G, Canca-Cabrera A.
    Foot (Edinb). 2010 Oct 18. [Epub ahead of print]
  15. bob

    bob Active Member

    The best person to talk about this with is your local microbiologist. Read up about local resistance patterns and antibiotic prescribing. Flucloxacillin is commonly used for staph aureus, as are cephalosporins and some of the macrolides in patients with penicillin allergy. There is a small percentage of patients with a penicillin allergy that will have a similar reaction to cephalosporins due to their chemical structure similarities. Aside from speaking to microbiology, go and spend time in your local multidisciplinary foot clinic. This will give you the best real world experience of antibiotic provision for foot infections, but microbiology links will keep you up to date as local resistance patterns change.

    Amoxicillin is susceptible to beta-lactamases, so would not be particularly effective against staph aureus - unless combined with clavulanic acid (a beta-lactamase inhibitor).

    Having said all this, spreading cellulitis is not usually caused by staph aureus, so you have to go on clinical signs, your knowledge of infection and advice from micro (and possibly blood cultures, although these are not particularly specific) to choose a reasonable antibiotic in these cases. Cellulitis is often caused by some form of streptococcus and may respond to amoxicillin (but, again, check with local practices). As others have said, you need to remove the nail spike too or in isolation depending on extent of infection.
  16. NewsBot

    NewsBot The Admin that posts the news.

    Postoperative Infection After Excisional Toenail Matrixectomy
    A Retrospective Clinical Audit

    Alen Rusmir and Angelo Salerno
    JAPMA July/August 2011 vol. 101 no. 4 316-322
  17. cyril20th

    cyril20th Member

    I sometime found a simple solution of Hydrogen Peroxide 10 vls would flush a lot of infection out. Not always by any means, but worth a try. If the infection was bad a doctors referral was needed. God Bless Cyril almond

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