What is the recommended treatment for paronychia?

Treatment of Paronychia

For paronychia treatment, the recommended approach includes warm soaks, topical treatments (2% povidone-iodine twice daily for grade 1-2 paronychia), topical corticosteroids with or without antibiotics, and surgical drainage for severe cases with abscess formation. 1, 2, 3

Classification and Diagnosis

Paronychia is inflammation of the tissue surrounding the nail and can be classified as:

• Acute paronychia: Usually caused by direct or indirect trauma to the cuticle or nail fold, allowing pathogens to enter and cause infection 4
• Chronic paronychia: Multifactorial inflammatory reaction lasting at least six weeks, representing an irritant dermatitis to the breached nail barrier 3, 5

Treatment Algorithm

Acute Paronychia

1. First-line treatment:

   • Warm soaks with or without Burow solution or 1% acetic acid 3
   • Topical povidone iodine 2% twice daily (showed benefit in controlled studies) 1, 2
   • Avoid trauma to the affected area

2. For mild to moderate inflammation without abscess:

   • High-potency topical corticosteroids alone or combined with topical antibiotics 1, 3
   • Silver nitrate chemical cauterization may be considered 1

3. For abscess formation:

   • Surgical incision and drainage is mandatory 3
   • Options range from using a hypodermic needle to a wide incision with a scalpel 3
   • Oral antibiotics are usually not needed if adequate drainage is achieved, except in immunocompromised patients or severe infections 3

Chronic Paronychia

1. First-line treatment:

   • Eliminate exposure to irritants and allergens 3, 5
   • Topical corticosteroids (more effective than systemic antifungals) 4, 5
   • Daily application of emollients to cuticles and periungual tissues 1, 2

2. For fungal involvement:

   • Combination of broad-spectrum topical antifungal agent with a corticosteroid 4
   • Consider topical formulations containing antifungals (like octopirox and climbazole) with anti-inflammatory agents 6

3. For recalcitrant cases:

   • En bloc excision of the proximal nail fold 4, 5
   • Eponychial marsupialization, with or without nail removal 4, 5
   • Swiss roll technique for severe cases 7

Preventive Measures

Patient education with preventive measures should be systematically promoted:

• Gentle skin care
• Avoid repeated friction, trauma, and excessive pressure
• Wear gloves while cleaning
• Avoid biting nails or cutting nails too short
• Regular trimming of nails ensuring they are straight and not too short
• Daily application of topical emollients to cuticles
• Wear comfortable well-fitting shoes and cotton socks 1, 2

Special Considerations

• For oncology patients: Paronychia is a common dermatological toxicity with anticancer agents, particularly EGFR inhibitors. Secondary bacterial or mycological superinfections are present in up to 25% of cases 1

• For diabetic patients: More vigilant monitoring and earlier intervention due to increased risk of infection; early referral to a foot care specialist is recommended 2

• For occupational paronychia: Common in housekeepers, dishwashers, bartenders, florists, and swimmers. Treatment should focus on stopping the source of irritation while treating inflammation 3, 6

Common Pitfalls to Avoid

• Failing to drain an abscess when present
• Using oral antibiotics unnecessarily when adequate drainage has been achieved
• Prolonged use of high-potency topical steroids, especially on the face
• Using topical steroids when infection is present without appropriate antimicrobial coverage
• Neglecting preventive measures, which are cornerstone of therapy, especially in chronic cases
• Delayed follow-up (patients should be reviewed within 48-72 hours if there are signs of infection) 2, 3