Ingrown toenail surgery aftercare: dressings, healing time and warning signs

Nail surgery is a minor procedure carried out under local anaesthetic. Kent Community Health NHS Foundation Trust says that part of the nail (partial nail avulsion) or the whole nail (total nail avulsion) is removed and a chemical, phenol, is applied to the nail bed to stop the nail growing back. No cutting or stitching of skin is involved, and a large dressing is applied afterwards.

The wound is an open area where the nail bed is exposed, and the phenol is there to destroy the nail-forming cells, so the wound takes weeks to heal and produces discharge. Bradford District Care NHS Foundation Trust says the open wound can become infected if not cared for properly, because the break in the skin provides a route for germs, and that taking extra care minimises the risk of infection, prevents delay in healing and reduces discomfort or scarring.

The NHS ingrown toenail page describes the operation only briefly, noting that a podiatrist may offer cutting away part of the nail or removing the whole nail, with a local anaesthetic to numb the toe. The detail on aftercare comes from NHS podiatry service leaflets, which differ in small ways, so follow the instructions you were given.

The local anaesthetic usually wears off after a couple of hours, according to Kent, and you may feel some discomfort. Guy's and St Thomas' NHS Foundation Trust says normal feeling returns 2 to 3 hours after the procedure, and to be careful until it does because you could injure your toe without realising.

All three services say to rest with the foot raised. Guy's and St Thomas' says to remove your footwear and rest with your legs raised for 2 to 3 hours to reduce the likelihood of bleeding, then to rest as much as possible for the rest of the day. Kent recommends resting with the foot up for the rest of the day and keeping the large dressing on and dry until the first re-dressing. If blood comes through, add more gauze over the top rather than removing the dressing. Bradford says the same.

For pain, Guy's and St Thomas' suggests regular painkillers such as paracetamol following the instructions on the packet, and Kent says not to take aspirin as it increases bleeding unless you take it as part of your normal medication. Bradford says people report minimal discomfort that can be controlled with paracetamol or ibuprofen.

You will have a bulky dressing, so open-toed footwear is advised for the journey home, and all three services advise against driving yourself home because of the anaesthetic.

The sources agree that the wound should be kept covered until it has stopped weeping, and that dressings should not be changed more often than needed, but they differ on the timetable. That is normal: each podiatry service has its own protocol. Your own written instructions are the ones to follow.

Kent says your first re-dressing appointment will be made within three days, either in clinic or virtually, that you leave the original dressing in place until then, and that after the first re-dressing you change the dressing once a day. For home dressings it suggests washing your hands, pouring pre-boiled but cooled salty water (a teaspoon of salt in a cup or jug) over the toe, gently patting dry, letting the wound dry naturally, using no creams, ointments or antiseptics, and covering with a clean dressing. It says you can stop dressing the toe as soon as the dressings come off clean for two consecutive days.

Guy's and St Thomas' books a re-dressing appointment for 1 to 4 days after surgery, where a smaller dressing is applied and you are shown how to look after the toe until it is fully healed, usually 4 to 6 weeks. Bradford says to change the first dressing five to seven days after surgery and then every three days, keeping the toe covered until you get two dressings with no discharge, and that changing dressings too often makes the wound heal more slowly because it cools down and dries out too quickly.

Many people are alarmed by discharge from a toe that was meant to be fixed. Kent says it is normal for the wound to weep a light-yellow discharge and for the area where the nail was removed to be inflamed or have a slight blister, and that three to 14 days after surgery there is usually an increase in discharge, so it is likely to look worse before it gets better. It says this is due to the chemical used and does not mean the toe is infected, and that a scab gradually forms and the discharge reduces, with the scab eventually coming away to reveal toughened skin over the nail bed.

Bradford warns about phenol burn: the chemical used to destroy nail cells can spread to the surrounding skin and delay healing. It says not to poke, pick or prod the wound, and to soak a stuck dressing off in warm water rather than pulling it.

Healing times are given as ranges. Kent says on average four to six weeks if part of the nail is removed and 10 to 12 weeks if the whole nail is removed. Bradford says if you generally heal well it should take 6 to 8 weeks to fully heal a partial nail removal and up to 12 weeks for a total nail removal. Guy's and St Thomas' says fully healed is usually 4 to 6 weeks.

Kent says that after the first re-dressing the dressing is much smaller and allows ordinary shoes, and that your toe heals more quickly if nothing presses on or squashes the wound. Guy's and St Thomas' says you can wear your normal footwear again after the first re-dressing appointment. Bradford says that if your toe is uncomfortable your shoes may be too tight and that you may need more room around the toes.

On bathing, Kent says you can bath or shower before putting a new dressing on but not to get the toe wet for too long because it slows healing. Bradford says to keep the toe dry for the first five days, especially while washing, and that after that you can remove the bandage and bathe as normal.

On activity, Kent says you can walk and carry on your life as normal but should avoid swimming and sporting activities that may injure the toe. On work, both Kent and Bradford say to rest at first, with Kent suggesting not returning to work immediately and perhaps staying off until the first re-dressing, and Bradford asking people with very active jobs or special footwear to discuss it before surgery.

A little redness, a small amount of swelling and light-yellow discharge are normal in a healing wound, according to Kent. It asks you to contact the podiatry service or your GP or NHS 111 as soon as possible if there is a significant increase in redness that spreads, warmth, swelling, pain or tenderness, thick yellow, green or cloudy discharge, an unpleasant smell, a wound getting larger instead of healing, or if you feel generally unwell or develop a fever. Bradford says that if the toe is hot, red, swollen with pus, it may be infected and you need to talk to your podiatrist or GP as soon as possible.

Diabetes changes the calculation. Kent says people with diabetes should not ignore signs of a foot infection because these can become serious very quickly and increase the risk of hospital admission, surgery or amputation if not treated promptly, and that you should not wait until the next working day if symptoms are getting worse. The NHS ingrown toenail page also lists diabetes among the reasons to see a GP for an ingrown toenail.

Guy's and St Thomas' says to go to an emergency podiatry clinic, or outside its hours your nearest emergency department, if there is a lot of bleeding that does not stop after following the aftercare instructions, or other difficulties such as severe pain or infection. Kent lists sepsis warning signs, such as confusion, severe shivering, passing little or no urine or severe breathlessness, as reasons to call 999.

Guy's and St Thomas' says nail surgery generally provides a permanent and safe answer to painful ingrown toenails, and that the removed section of nail might regrow and need to be removed again, which happens in fewer than 5 in every 100 cases. Kent lists regrowth, wound infection, slower-than-average healing, allergic reaction, scarring and a longer-than-usual anaesthetic effect among the risks, and says that if both sides of the nail are removed you may temporarily lose the remaining nail and the new nail edge may be temporarily irritated while it grows out.

The NHS ingrown toenail page gives prevention advice for the future: do not cut toenails too short, cut straight across rather than at the edges, do not wear shoes that are too tight or do not fit, and keep feet clean and dry.