Chronic Infected Ingrown Toenail with Concerning Erythematous Changes

Case at a Glance

An 18-year-old female presents with a 5-year history of chronic infected ingrown toenail complicated by dermatillomania and concerning new erythematous changes suggesting possible cellulitis extension.

Patient's Story

The patient reports a persistent ingrown toenail infection lasting approximately 5 years that has been refractory to multiple conservative treatments. She has a history of dermatillomania with compulsive picking at the affected area, which she acknowledges may be contributing to poor healing. The patient expresses concern about a newly developed red spot adjacent to the chronically infected area, accompanied by intermittent purulent and bloody drainage. She reports minimal pain and maintains normal ambulation. The patient has financial constraints and limited insurance coverage, leading her to delay seeking immediate medical care unless absolutely necessary.

Initial Assessment

The patient appeared well but demonstrated visible signs of chronic infection at the lateral aspect of the great toenail. Physical examination revealed erythema, edema, and purulent drainage consistent with chronic paronychia. New concerning finding included a discrete erythematous area adjacent to the primary infection site, raising concern for cellulitis extension. The patient exhibited normal vital signs and ambulatory function.

The Diagnostic Journey

Initial conservative management over several years included warm water soaks, Epsom salt baths, topical antibiotic ointments, and cotton wedging techniques to redirect nail growth. Patient admits to self-performed nail removal during adolescence, which likely complicated the condition. Current presentation with new erythematous changes prompted evaluation for potential complications including cellulitis or lymphangitis.

Final Diagnosis

Chronic infected ingrown toenail (onychocryptosis) with secondary bacterial infection and possible early cellulitis. Complicated by dermatillomania and previous improper self-treatment.

Treatment Plan

Immediate recommendations include urgent care evaluation for possible antibiotic therapy given concerning erythematous changes. Patient counseled on warning signs requiring emergency care including ascending erythema, red streaking, fever, or systemic symptoms. Long-term management will likely require surgical intervention such as partial nail avulsion with phenolization. Behavioral counseling for dermatillomania management recommended.

Outcome and Follow-up

Patient advised to seek prompt medical attention despite financial concerns due to risk of systemic infection. Scheduled for routine follow-up to reassess and plan definitive surgical management. Patient education provided regarding proper wound care and cessation of picking behaviors to prevent further complications.