What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should be tailored based on whether it is acute or chronic, with acute cases requiring warm soaks with or without Burow solution or 1% acetic acid, followed by topical antibiotics if simple soaks don't relieve inflammation, and drainage if an abscess is present. 1

Acute Paronychia Management

Initial Conservative Treatment

• Begin with warm soaks 3-4 times daily for 15 minutes
  • Can use plain warm water
  • May add Burow solution or 1% acetic acid to the soaks 1
• If simple soaks don't provide relief, add topical antibiotics
  • Mupirocin ointment applied three times daily is effective 2
  • Patients should be re-evaluated if no clinical response within 3-5 days 2

Abscess Management

• Assess for presence of abscess, which requires drainage 1
• Drainage options include:
  • Simple instrumentation with a hypodermic needle
  • Incision and drainage with a scalpel 1
• After drainage:
  • Clean the nail bed
  • Obtain cultures if infection is suspected
  • Apply topical antibiotic ointment and sterile dressing 3

Antibiotic Therapy

• Oral antibiotics are generally not needed if adequate drainage is achieved
• Exceptions include:
  • Immunocompromised patients
  • Severe infections
  • Diabetic patients (require more vigilant monitoring) 3, 1
• When selecting antibiotics, consider local resistance patterns 1

Chronic Paronychia Management

Addressing Root Causes

• Identify and eliminate irritants and allergens 4
• Keep hands and feet dry
• Trim nails straight across
• Wear properly fitting shoes with adequate toe box 3

Medication Therapy

• Topical steroids have been found more effective than antifungals 4
• Topical calcineurin inhibitors may be used as alternatives 1
• For fungal infections, appropriate antifungal treatment should be initiated 3, 4

Refractory Cases

• For resistant cases, surgical options include:
  • En bloc excision of the proximal nail fold
  • Eponychial marsupialization (with or without nail plate removal) 4
  • Swiss roll technique for severe cases 5

Special Considerations

Paronychia with Nail Detachment

• If the nail is significantly detached, causing pain, or showing signs of infection, complete removal is recommended 3
• The space between a partially detached nail and nail bed creates an ideal environment for bacterial growth 3

High-Risk Patients

• Diabetic patients require more vigilant monitoring and earlier intervention 3
• Consider early referral to a foot care specialist for diabetic patients 3
• Oncology patients on taxane therapy with onycholysis may require partial or total nail avulsion for Grade 2 treatment with painful hematoma or subungual abscess 3

Follow-up Care

• Review within 48-72 hours if signs of infection are present
• Otherwise, follow up in 1-2 weeks to ensure proper healing 3
• For chronic cases, treatment may take weeks to months, and patient education is crucial to prevent recurrence 1

Common Pitfalls to Avoid

• Failing to drain an abscess when present
• Unnecessary use of oral antibiotics for simple cases
• Overlooking underlying causes in chronic paronychia
• Not considering systemic conditions or medications that may cause nail changes 6
• Ignoring the need for patient education on preventive measures, which is paramount to reduce recurrence 1