How do you treat pilonychia?

Treatment of Paronychia

The first-line treatment for paronychia includes warm soaks, topical povidone-iodine 2% twice daily, and avoiding trauma to the affected area. 1 For mild to moderate inflammation without abscess, high-potency topical corticosteroids alone or combined with topical antibiotics are recommended.

Diagnosis and Classification

Paronychia is inflammation of the fingers or toes in one or more of the three nail folds. It can be classified as:

• Acute paronychia: Caused by polymicrobial infections after the protective nail barrier has been breached 2
• Chronic paronychia: Characterized by symptoms of at least six weeks' duration, representing an irritant dermatitis to the breached nail barrier 2

Treatment Algorithm

1. Acute Paronychia Without Abscess

• First-line therapy:

  • Warm soaks with or without Burow solution or 1% acetic acid 2
  • Topical povidone-iodine 2% twice daily 1
  • Avoid trauma to the affected area 1

• If simple soaks don't relieve inflammation:

  • Add topical antibiotics with or without topical steroids 2
  • Daily application of emollients to cuticles and periungual tissues 1

2. Acute Paronychia With Abscess

• Mandatory drainage of the abscess 1, 2

• Drainage options range from:

  • Instrumentation with a hypodermic needle
  • Wide incision with a scalpel 2

• Post-drainage care:

  • Topical antibiotics if indicated
  • Regular dressing changes
  • Elevation and limited weight-bearing initially 1

• Oral antibiotics are usually not needed if adequate drainage is achieved, except in:

  • Immunocompromised patients
  • Severe infections 1, 2

3. Chronic Paronychia

• Treatment approach:
  • Identify and eliminate the source of irritation 2
  • Apply topical steroids or calcineurin inhibitors 2
  • For fungal involvement, consider combination of broad-spectrum topical antifungal agent with a corticosteroid 1
  • More aggressive techniques may be required to restore the protective nail barrier 2

Special Considerations

For Fungal Involvement (Onychomycosis)

• First-line treatments for dermatophyte onychomycosis:
  • Itraconazole: 200 mg per day for 12 weeks continuously, or as 'pulse therapy' at 400 mg per day for 1 week per month (two pulses for fingernails, three for toenails) 3
  • Terbinafine: Generally preferred over itraconazole, 250 mg per day for 6 weeks in fingernail and 12–16 weeks in toenail infection 3

For Partially Detached Nails

• Completely remove nails if significantly detached or causing pain
• Clean and culture the nail bed
• Apply appropriate antibiotics if infection is suspected 1

Prevention Strategies

Patient education with preventive measures should be systematically promoted:

• Gentle skin care
• Preventive correction of nail curvature with referral to a podiatrist if needed
• 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 and periungual tissues
• Wear comfortable well-fitting shoes and cotton socks 3, 1

Common Pitfalls and Caveats

1. Misdiagnosis: Paronychia can be confused with other conditions like herpetic whitlow or onychomycosis. Proper diagnosis is essential for appropriate treatment.

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

3. Overlooking fungal superinfection: Secondary fungal infections are present in up to 25% of cases 3. Consider antifungal treatment if not responding to standard therapy.

4. Ignoring underlying causes: For chronic paronychia, failure to identify and eliminate the source of irritation will lead to recurrence 2.

5. Recurrence risk: Onychomycosis has high recurrence rates (40-70%) 3. Emphasize preventive measures to avoid reinfection.

6. Monitoring complications: Watch for potential complications including permanent nail deformity, secondary infection, and permanent onycholysis 1.

Treatment may take weeks to months, especially for chronic paronychia. Patient education is paramount to reduce the recurrence of both acute and chronic paronychia 2.