What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should be based on whether it is acute or chronic, with acute paronychia requiring warm soaks with or without Burow solution or 1% acetic acid, topical antibiotics with or without steroids, and drainage if an abscess is present, while chronic paronychia requires elimination of irritants and application of topical steroids or calcineurin inhibitors. 1, 2

Classification and Diagnosis

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

• Acute paronychia: Usually caused by bacterial infection (commonly Staphylococcus aureus or Streptococcus) after the protective nail barrier has been breached 2, 3

  • Severity grades:
    • Grade 1: Mild inflammation
    • Grade 2: Moderate inflammation
    • Grade 3: Severe, requiring medical evaluation and possible surgical intervention 1

• Chronic paronychia: Symptoms lasting at least six weeks, representing an irritant dermatitis to the breached nail barrier 1, 2

Treatment Algorithm for Acute Paronychia

1. Initial management:

   • Warm soaks with or without Burow solution or 1% acetic acid for 15-20 minutes, 2-3 times daily 2
   • Gently wash the affected area with mild soap and lukewarm water, pat dry thoroughly 1

2. If simple soaks don't relieve inflammation:

   • Apply topical antibiotics with or without topical steroids 2
   • For mild to moderate inflammation without abscess, high-potency topical corticosteroids alone or combined with topical antibiotics 1

3. If abscess is present:

   • Surgical drainage is mandatory 1
   • Drainage options range from using a hypodermic needle (21G or 23G) to lift the nail fold to a wide incision with a scalpel 2, 4
   • For paronychia associated with an ingrowing toenail, treatment should address the causal toenail 5

4. Antibiotic therapy:

   • Oral antibiotics are usually not needed if adequate drainage is achieved 1, 2
   • Exception: immunocompromised patients or severe infections 1
   • Base therapy on most likely pathogens and local resistance patterns 2
   • For penicillin-allergic patients, clindamycin is recommended 1

Treatment Algorithm for Chronic Paronychia

1. Identify and eliminate irritants:

   • Common irritants include acids, alkalis, and chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 2

2. Topical therapy:

   • Topical steroids (high-potency) are more effective than antifungals 6
   • Calcineurin inhibitors may be used as an alternative 2
   • Topical antiseptics such as povidone-iodine 2% twice daily can be applied to the proximal part of the nail 1
   • An imidazole lotion alternating with an antibacterial lotion is usually effective 1

3. For recalcitrant cases:

   • Surgical treatment may be necessary, including en bloc excision of the proximal nail fold or eponychial marsupialization, with or without nail plate removal 6
   • Dermatology consultation should be obtained 5
   • Investigate for unusual causes such as malignancy if unresponsive to standard treatment 5

Special Considerations

• Fungal superinfections: Present in up to 25% of cases; consider antifungal treatment if not responding to standard therapy 1
• Diabetic patients: Require more vigilant monitoring and earlier intervention due to increased risk of infection 1
• Immunocompromised patients: Should be especially cautious about infection risk 1
• EGFR-TKI-related paronychia: Common side effect of cancer treatments that may require dose reduction or interruption of medication 7

Prevention

• Keep hands and feet as dry as possible; avoid prolonged soaking in water 7, 1
• Apply daily topical emollients to cuticles and periungual tissues 1
• Regular nail trimming, ensuring they are straight and not too short 1
• Avoid repeated friction, trauma, and excessive pressure to the nail area 1
• Wear gloves while cleaning or doing wet work 1
• Avoid biting nails or cutting nails too short 1

Follow-up

• Return for follow-up within 1-2 weeks to ensure proper healing 1
• Return within 48-72 hours if signs of infection are present 1
• Treatment may take weeks to months, especially for chronic paronychia 1
• Monitor for complications including permanent nail deformity, secondary infection, and permanent onycholysis 1