What is the best treatment for paronychia?

Treatment of Paronychia

The best treatment for paronychia is a graded approach based on severity, starting with topical povidone iodine 2% twice daily for mild cases, progressing to topical antibiotics/corticosteroids for moderate cases, and oral antibiotics or surgical intervention for severe cases. 1

Classification and Assessment

Paronychia is an inflammation of the tissues surrounding the nail fold that can be:

• Acute paronychia: Sudden onset, painful erythematous inflammation with swelling
• Chronic paronychia: Symptoms lasting at least six weeks, representing irritant dermatitis

Severity grading (according to CTCAE v5.0):

• Grade 1: Nail fold edema or erythema; disruption of the cuticle
• Grade 2: Nail fold edema or erythema with pain; discharge or nail plate separation
• Grade 3: Requiring surgical intervention; limiting self-care activities

Treatment Algorithm

Grade 1 (Mild) Paronychia

1. Continue normal activities but monitor for worsening
2. First-line treatment:
   • Topical povidone iodine 2% twice daily 1
   • Warm water soaks for 15 minutes 3-4 times daily 1
   • White vinegar soaks (1:1 white vinegar:water) for 15 minutes daily 1
3. If no improvement after 2 weeks, progress to Grade 2 treatment

Grade 2 (Moderate) Paronychia

1. Continue normal activities but obtain bacterial/fungal cultures if infection is suspected
2. Treatment options:
   • Topical povidone iodine 2% plus topical antibiotics and corticosteroids 1
   • Oral antibiotics if signs of spreading infection 1
   • For chronic cases, consider topical calcineurin inhibitors 2
3. If no improvement after 2 weeks, progress to Grade 3 treatment

Grade 3 (Severe) or Intolerable Grade 2 Paronychia

1. Obtain bacterial/fungal cultures if infection is suspected
2. Treatment options:
   • Topical povidone iodine 2% plus topical antibiotics and corticosteroids 1
   • Oral antibiotics based on culture results 1
   • Surgical intervention: Partial nail avulsion for drainage if abscess present 1, 2
3. Reassess after 2 weeks; if worsening, consider more aggressive surgical approach

Prevention Strategies

Prevention is critical, especially for those at risk of recurrence:

• Avoid nail trauma and excessive moisture
• Wear gloves while cleaning or working with irritants
• Avoid biting nails or cutting them too short
• Regular trimming of nails (straight across, not too short)
• Daily application of emollients to cuticles and periungual tissues
• Wear comfortable, well-fitting shoes 1

Special Considerations

• Secondary infections: Present in up to 25% of cases, both gram-positive and gram-negative organisms may be involved 1
• Chronic paronychia: Represents irritant dermatitis and may require longer treatment (weeks to months) 2
• Occupational factors: Common in housekeepers, dishwashers, bartenders, florists, and swimmers due to chemical exposure 2
• Fungal involvement: Consider antifungal treatment if Candida is suspected, especially in chronic cases 3

Common Pitfalls to Avoid

1. Failure to drain abscesses: When fluctuance is present, drainage is mandatory for proper healing
2. Overuse of antibiotics: Oral antibiotics are usually unnecessary if adequate drainage is achieved 2
3. Ignoring underlying causes: Chronic paronychia often has occupational or systemic triggers that must be addressed
4. Inadequate follow-up: Paronychia can rapidly progress from Grade 1 to Grade 2, requiring prompt reassessment
5. Missing malignancy: Chronic, treatment-resistant paronychia should prompt investigation for unusual causes, including malignancy 4

By following this treatment algorithm based on severity grading, most cases of paronychia can be effectively managed with good outcomes for morbidity, mortality, and quality of life.