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paronychia
A paronychia is an infected ingrown toenail caused when a sharp nail edge pierces the surrounding skin, allowing bacteria to enter and create a painful infection. It may also result from trauma, repetitive micro‑injury (such as in soccer or tennis), or improper nail‑cutting techniques, including overly aggressive pedicures.
This infection rarely resolves on its own. If the nail continues to penetrate the skin, the area typically becomes increasingly swollen, red, and tender. In healthy individuals, the infection may remain localized, but in diabetics or those with poor circulation, it can spread rapidly and lead to ascending cellulitis, tissue breakdown, or even gangrene.
Long‑standing or severe cases may allow bacteria to reach the underlying bone, resulting in osteomyelitis—a serious condition that may require surgical removal of infected bone. For this reason, persistent or worsening paronychia often warrants imaging and professional evaluation.
Treatment typically requires removing the offending portion of nail. Antibiotics alone are usually ineffective because the nail continues to re‑pierce the skin. For recurrent cases, a permanent procedure may be performed to remove the ingrown portion of the nail root (matrixectomy). Granulomas—bright red, easily bleeding tissue sometimes seen alongside chronic ingrown nails—are usually cauterized during treatment and should be biopsied if they recur.
Until professional care is available, warm salt‑water soaks and topical antibiotic ointment can help reduce discomfort. Preventive measures include cutting nails straight across, avoiding digging into nail corners, wearing shoes with a wide toe box, and avoiding pedicurists who attempt to remove ingrown nails.
Reviewed by: Medical Review Board
WHAT IS A PARONYCHIA
This is an infected ingrown toe nail. It is generally the result of an ingrown nail piercing the surrounding flesh, bacteria the gets into the opening and it becomes infected. Less commonly the cause can be from trauma to the nail such as dropping something on the toe, or what I like to refer to as micro trauma which is repeated pressure against the nail as might be seen in someone who plays soccer or tennis where the toe is constantly being jammed into the end of the athletic shoe.
Another cause of a paronychia is poor cutting technique of the patient in trimming their own nails. People have come to me as a result of using a nail salon where the pedicurist attempted to cut out an ingrown nail, only to see it get infected.
Below is a picture of an infected ingrown toe nail (paronychia)
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This is a bacterial infection which needs medical attention. Aside from the pain factor if left alone the infection can spread. Generally in a healthy individual you will see a reactive cellulitis which is redness in the immediate surrounding area. However, in a diabetic or person with poor circulation or other debilitating illness, the infection can spread and you may see an ascending cellulitis meaning the redness travels up the foot, possibly up to the leg.
In these same individuals the tissue in the infection site may begin to breakdown leading to ulceration or gangrene (depending on how bad the circulation is).
In other instances, in an untreated ingrown toe nail, the bacteria may invade the adjacent bone leading to a bone infection known as osteomyelitis. As you can imagine a bone infection is a very serious problem and may require surgical removal of the infected bone. If you present to your doctor's office with a longstanding paronychia, your doctor may order an x-ray of the ingrown toe nail.
It has been my experience that rarely a paronychia clears up on its own, although it can happen. More likely the portion of ingrown toe nail will have to be removed. Many times this can be done without local anesthesia, but sometimes the toe does have to be put to sleep in order to remove the offending nail. If a patient comes to the office with a first time problem, I generally just remove the ingrown nail with the understanding that the piece of nail removed will grow back.
However, if a patient develops a recurring problem I generally recommend an office procedure whereby the offending piece of nail is removed on a permanent basis. It is important to note, that only the ingrown portion of the nail not the whole nail needs to be removed.
Below is a video of a phenol and alcohol technique (P&A), for removing an ingrown toe nail. This is an office procedure done under local anesthesia. After the ingrown nail is removed the growth plate (matrix) is destroyed using repeated applications of phenol, a matrixectomy. The remaining phenol is then neutralized by applying alcohol to the area. (This surgical video was not performed by me.)
TREATMENT FOR INGROWN TOE NAIL
In most cases an antibiotic without nail removal will not work. What I have seen over the years is patients who were put on oral antibiotics by their primary care doctor and while the toe seemed to improve while they were on the medication as soon as they finished they ended up with a worsening of the toe. If the nail is piercing the flesh it is almost always going to re-infect unless it is removed.
care of paronychia before seeing the doctor
Should you develop a paronychia or even just a painful ingrown nail, the best thing you can do initially until you can seek treatment is to soak the foot in a solution of table salt or Epsom salt using one tablespoon per quart of warm (not hot) water for 15-20 minutes. If the solution burns then reduce the amount of salt. After soaking, apply an antibiotic ointment and dressing. Not only will the ointment help the infection but it will soften the surrounding skin making the toe less painful. Do this repeatedly until you can have professional care.
If you are diabetic or have compromised circulation, seeking immediate medical care is mandatory.
Sometimes patients will present with a paronychia that has a bright red growth coming out of the side of ingrown nail. This is known as a granuloma. It is an accumulation of blood cells, bacteria and scar tissue. In itself it is nothing serious other than it tends to bleed a lot if traumatized.
When the ingrown nail is removed we generally cauterize the granuloma. One word of caution; if the granuloma keeps coming back (with or without an ingrown nail) it should be removed and biopsied. In very rare instances these innocuous granulomas may actually be a melanoma, which is a very serious skin cancer. It requires immediate medical attention.
PREVENTING INGROWN NAILS
Unfortunately, there are some nails that are just predisposed to growing inward. Examples would include nails that have been subjected to trauma, nails that have fungus underneath them which forces the center of the nail upwards while causing the sides to grow into the flesh. Abnormally shaped medial and lateral nail folds may also predispose nails to grow in and become painful. Lastly, nails that are very thin and hard which makes them very sharp will also tend to cause ingrown nails.
For the rest of you, there are some simple things you can do to prevent normally growing nails from becoming chronic ingrown nails.
1. cut your nails straight across and avoid cutting down the sides of the nails.
2. avoid nail salons as many pedicurists think they are amateur foot doctors and try cutting out ingrown nails usually ending up creating infections.
3. actually cutting your nails with a sharp instrument instead of trying to "pick" the nail and end up leaving rough edges particularly on the side of the nail.
4. wear shoes with a wide toe box and lower heel in order to not force your toes into the end of the shoe.
5. believe it or not, sometimes foot structure can aggravate an ingrown nail. An example would be a bunion deformity, which might aggravate the nail on the inside of the nail. In some cases the bunion may have to be corrected in order to alleviate chronic ingrown nail pain.
6. nail fungus may exacerbate ingrown nail pain. Clearing up the fungus can help relieve the pain from ingrown nails.
Frequently Asked Questions
What exactly is a paronychia?
A paronychia is a bacterial infection of the skin surrounding an ingrown toenail. It typically occurs when an ingrown nail pierces the surrounding flesh, allowing bacteria to enter the opening. While usually caused by ingrown nails, it can also result from trauma to the toe or poor nail-trimming techniques.
Can a paronychia be treated with just antibiotics?
In most cases, antibiotics alone will not work if the nail is still piercing the flesh. While the infection may seem to improve during the course of medication, it often returns once the antibiotics are finished. Professional removal of the offending piece of nail is usually required to resolve the infection permanently.
What are the risks of leaving an infected toenail untreated?
If left untreated, the infection can spread, leading to cellulitis (redness spreading up the foot or leg). In more severe cases—particularly for those with diabetes or poor circulation—it can lead to tissue breakdown, gangrene, or a serious bone infection known as osteomyelitis.
How can I manage the pain before my doctor's appointment?
You can perform immediate home care by soaking the foot in a solution of warm water and table salt (or Epsom salt) for 15-20 minutes. Following the soak, apply an antibiotic ointment and a dressing to help soften the skin and reduce pain.
How can I prevent ingrown toenails from becoming infected?
To prevent future infections, Dr. Marc Mitnick recommends several steps:
- Cut nails straight across and avoid rounding the corners.
- Use sharp instruments rather than "picking" at the nail.
- Wear shoes with a wide toe box to prevent crowding.
- Avoid professional pedicures if they involve "digging out" corners.
REFERENCES
Questions I Have Answered From Visitors
Location: South Texas
Q: "I had my toenail chemically removed over 1 year ago. Since then I have had pain (they tell me it's nerve pain) and numbness in my big toe. The area is hypersensitive to the slightest touch—even the weight of a comforter wakes me up. I’ve seen an MD and a podiatrist, but the only options offered were urea lotion or surgically removing the skin, with no certain outcome. Is there a real treatment for this?"
A: Hi Larry, while I have performed thousands of chemical matrixectomies, the level of chronic hypersensitivity you are describing a year later is quite rare. Here are the primary clinical possibilities for why you are still in pain:
- Traumatic Neuritis: It is possible the needle struck a digital nerve during the initial numbing injection. While this usually resolves within a year, persistent inflammation (neuritis) can occasionally cause long-term localized numbness or burning.
- Chemical Burn: If the chemical used during the procedure was too strong or left in too long, you may have suffered a deep tissue chemical burn. This can leave the nail bed tissue abnormally sensitive even after the skin appears healed.
- Hyperkeratotic Tissue: If there is excess hard skin over the nail bed, it can press against underlying nerves. If urea cream provided even slight relief, having a podiatrist gently debride (scrape) the excess tissue may help.
I recommend seeking a second opinion from a different podiatrist. In the meantime, you might ask about using small lidocaine patches on the top of the toe to dampen the nerve response and help you sleep.
Marc Mitnick, DPM
Visitor Name: Nicole
Location: Brooklyn, NY
Hi Nicole,
Unfortunately, it sounds like you are going to need some medical care. I say this because the green discoloration is not a good thing. It either represents a fungal infection underneath the nail or even the possibility of a bacterial infection. Neither of these conditions is good to have.
In order to save the nail from permanent discoloration and thickness, the green discoloration and the bleeding underneath the nail needs to be treated. When you have trauma to a nail and there is bleeding underneath and in your case a probable infection, this all has to be cleaned up.
Because of this situation the nail has lifted off its nail bed. By doing so you have dramatically increased the odds that there may be permanent damage to the nail and eventually the whole nail will become deformed leaving you with a very unsightly nail for the rest of your life. In fungus infections when one nail is affected it can easily spread to the adjacent toes and then all your nails become deformed.
In bacterial infections you run the risk of a cellulitis and spreading of the infection. I should note that if you are young and in good health there is less chance of this happening but walking around even with a minor infection is not a healthy situation.
Treatment is probably not as bad as it may sound. In my office, I can usually cut away and drain a portion of the nail to clean up the green discoloration and any residual blood that may be underneath the nail. Rarely does the whole nail have to be removed.
Depending on how much damage you actually did to the nail, at some point you may actually lose the nail. If the nail was traumatized enough, a new nail starts to grow underneath the old nail. At first you will not notice anything, but then all of a sudden you will start to notice that the old nail is starting to loosen up.
My suggestion is to not wait for this to happen, because at that point the new nail may be so damaged that you will end up with the type of nail deformity I have just described.
So, my advice to you is to see a local foot specialist and let he or she evaluate the situation. The doctor will decide to what extent the nail needs to be treated and this will dramatically reduce the possibility of having problems going forward.
Marc B. Mitnick, DPM
Visitor Name: Brooke
Location: Pennsylvania
Hi Brooke,
When there is trauma to a nail such as in your case of stubbing it, what happens is there may be bleeding underneath the nail as the result of the nail being jammed back into the toe, thus lifting the nail slightly and causing it to bleed.
In more severe cases there can be so much bleeding that pain can ensue as well as the possibility of infection. Your case is the more common situation. We also see this in runners, tennis players, basketball players, etc. where the constant jamming of the toe into the sneaker causes the same effect.
Here is what I would recommend. If the toes does not hurt leave it alone. Nails can take months to fully grow out. What you should be seeing is a gradual movement forward of the discoloration with clear nail behind it. Eventually the discolored nail will grow forward and will be replaced by normal nail.
Now, if for some reason this does not occur with you then you will need to have the nail examined by a podiatrist. Since there was a history of trauma, it is safe to assume that the discoloration was the result of the trauma, however, in some cases discoloration of the nail can be due to a growth on the nail bed.
So over time if the nail does not improve, the nail may have to be removed in order for the doctor to examine the nail bed to make sure there is nothing abnormal going on. Again, because of the history of trauma, I do not think there is a growth on the nail bed, but the trauma may have damaged the growth plate of the nail and that may have to be explored as well.
It is now about three months since the trauma. I would give it another two months or so. If the nail does not appear to be improving then it might be time for a podiatrist to take a look at it to make sure there is nothing else going on. Because the problem is occurring underneath the nail there is nothing you can really do for it on your own, other than applying nail polish to cover the discoloration.
As a side note, if you eventually have to seek medical care make sure you remove any nail polish prior to the visit.
Marc B. Mitnick, DPM
If you happen to live in the New York - New Jersey area and would like to visit our office
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DISCLAIMER: The purpose of this site is purely informational in nature. It is not intended to diagnose, treat or cure any medical condition. This information is not a substitute for advice from a medical professional. Please consult your healthcare provider for accurate diagnosis and treatment. The information presented here may be subject to errors and omissions.
SITE LAST UPDATED: MAY 2026
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anonymous
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location unknown
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New Jersey
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San Diego, CA
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Albany, NY
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Whichita, KS
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Colorado
Wonderful advice
by: Anonymous
This is the best site for foot problem info.
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by: Max
location unknown
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Canada
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Wisconsin
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North Carolina
Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...
KG
location unknown
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Florida
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Lynne T.
location unknown
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New Jersey
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a mom
location unknown
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Melody
Lenoir, NC
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Bellevue, WA
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Jodi
location unknown
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