What is the treatment for chronic paronychia?

Treatment of Chronic Paronychia

The most effective treatment for chronic paronychia includes topical corticosteroids combined with preventive measures, as topical steroid creams have been proven more effective than systemic antifungals for this condition. 1, 2

Understanding Chronic Paronychia

Chronic paronychia is an inflammatory disorder of the nail folds characterized by:

• Redness, tenderness, and swelling of the proximal nail fold
• Duration of at least six weeks
• Multifactorial inflammatory reaction to irritants and allergens
• Common in people with frequent water exposure (housekeepers, dishwashers, bartenders)

Treatment Algorithm

First-Line Treatment

1. Topical therapy:

   • Mid to high potency topical corticosteroid ointment applied to nail folds twice daily 3
   • Can be combined with topical antibiotics if secondary infection is suspected

2. Preventive measures (critical for long-term success):

   • Avoid water exposure; wear cotton-lined gloves when hands must be in water 3
   • Keep hands dry and apply emollients to cuticles and periungual tissues daily
   • Avoid trauma to the nail fold and cuticle
   • Avoid cutting nails too short or biting nails 3
   • Gentle nail care with regular straight trimming of nails

Second-Line Treatment

For cases not responding to first-line therapy:

1. Topical options:

   • Topical povidone iodine 2% twice daily (shown benefit in controlled studies) 3
   • Topical calcineurin inhibitors (for steroid-resistant cases) 4
   • Topical antifungals if fungal infection is confirmed

2. Oral therapy for recalcitrant cases:

   • Oral antibiotics if bacterial infection is confirmed by culture 3
   • Doxycycline 100 mg twice daily for recurrent, severe cases (follow up after 1 month) 3

Severe or Refractory Cases

For intolerable or treatment-resistant cases:

1. Surgical options:
   • En bloc excision of the proximal nail fold 2
   • Eponychial marsupialization with or without nail plate removal 2
   • Partial nail avulsion for cases with onychocryptosis (ingrown nail) 3

Special Considerations

For Cases with Secondary Infection

• Obtain bacterial/fungal cultures before initiating antibiotics 3
• Choose antibiotics based on culture results and local resistance patterns
• Drainage is essential if abscess is present 4

For Cases with Granulation Tissue

• Silver nitrate chemical cauterization 3
• Scoop shave removal with hyfrecation 3

Treatment Duration and Follow-up

• Reassess after 2 weeks of treatment 3
• If no improvement, proceed to next step in algorithm
• Treatment may take weeks to months for complete resolution 4
• Monitor for secondary infections which occur in up to 25% of cases 3

Common Pitfalls to Avoid

1. Misdiagnosis: Chronic paronychia is primarily an inflammatory condition, not primarily fungal - treating only with antifungals is a common mistake 1

2. Inadequate preventive measures: Treatment will fail if exposure to irritants continues 4

3. Premature treatment discontinuation: Chronic paronychia requires consistent therapy over weeks to months

4. Overlooking onychocryptosis: Ingrown nail can perpetuate inflammation and should be addressed with appropriate techniques (dental floss nail separation, splinting) 3

5. Excessive focus on antimicrobials: While secondary infections occur, the primary pathology is irritant dermatitis to a breached nail barrier 4

Patient education about the chronic nature of this condition and the importance of preventive measures is essential for successful management and prevention of recurrence.