What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should begin with warm water soaks for 15 minutes 3-4 times daily, topical 2% povidone iodine applied twice daily, and high-potency topical corticosteroids, with progression to surgical drainage for cases with abscess formation. 1

Classification and Initial Approach

Paronychia is inflammation of the nail folds that can be classified as:

1. Acute paronychia: Typically caused by polymicrobial infections after the protective nail barrier has been breached 2
2. Chronic paronychia: Characterized by symptoms lasting at least six weeks, representing an irritant dermatitis 2

Treatment Algorithm

Prevention Measures (For All Cases)

• Cut nails straight across, not too short, and avoid rounding corners 1
• Wear comfortable, well-fitting shoes and cotton socks 1
• Avoid repetitive trauma, friction, and excessive pressure to nails 1
• Wear gloves while cleaning 3
• Apply emollients daily to cuticles and periungual tissues 3
• Keep hands and feet as dry as possible 3

Mild Cases (Grade 1)

1. First-line treatments:

   • Warm water soaks for 15 minutes 3-4 times daily 1
   • White vinegar soaks (1:1 dilution) for 15 minutes daily 3, 1
   • Topical 2% povidone iodine applied twice daily 3, 1
   • High-potency topical corticosteroids applied to nail folds twice daily 3, 1
   • Topical antibiotics if signs of superficial infection 1

2. If no improvement:

   • Consider combination of topical antibiotics with corticosteroids 3
   • Taping with stretchable tapes to keep nail fold away from nail plate 3, 1

Moderate Cases (Grade 2)

1. Consider dose reduction or interruption of EGFR-TKI if applicable 3
2. Add oral antibiotics based on local resistance patterns 3
3. Apply silver nitrate weekly if over-granulation tissue has developed 3, 1
4. Consult dermatologist or podiatrist if no improvement 3

Severe Cases (Grade 3)

1. Surgical drainage is indicated for abscess formation 1, 2

   • Options include:
     • Needle aspiration
     • Incision and drainage
     • Partial nail avulsion

2. Discontinue EGFR-TKI if applicable until resolved to Grade 2 3

3. Swab any pus for culture and prescribe appropriate antibiotics 3

4. Continue topical treatments (steroids, antibiotics, antifungals) 3

Special Considerations

Chronic Paronychia

• Treatment is aimed at stopping the source of irritation while treating inflammation 2
• Topical steroids or calcineurin inhibitors are recommended 2, 4
• Treatment may take weeks to months 2
• Consider dermatology consultation 5
• Investigate for unusual causes (including malignancy) if unresponsive to standard treatment 5

Granulation Tissue Management

• Silver nitrate chemical cauterization 3, 1
• Timolol 0.5% gel, twice daily under occlusion 3, 1
• Cryotherapy for pyogenic granuloma 3, 1

Pitfalls and Caveats

1. Misdiagnosis: Chronic paronychia may be mistaken for fungal infection. Always consider non-infectious causes including irritant dermatitis 4

2. Inadequate drainage: Failure to properly drain an abscess can lead to persistent infection and worsening symptoms 2

3. Overlooking underlying causes: Chronic paronychia may be associated with systemic conditions or medications that need addressing 6

4. Delayed surgical intervention: Waiting too long for surgical management in cases with abscess formation can lead to complications 1

5. Insufficient patient education: Without proper education on preventive measures, recurrence is common 2

By following this structured approach to paronychia management, clinicians can effectively treat this common condition while minimizing complications and recurrence.