What is the recommended treatment for paronychia?

Treatment of Paronychia

The recommended treatment for paronychia depends on whether it is acute or chronic, with warm soaks (with or without Burow solution or 1% acetic acid) for 15-20 minutes, 2-3 times daily as the initial management for acute paronychia, while chronic paronychia requires identification and elimination of irritants along with topical steroids. 1

Acute Paronychia Management

Initial Treatment

• Begin with warm soaks with or without Burow solution or 1% acetic acid for 15-20 minutes, 2-3 times daily 1, 2
• If simple soaks don't relieve inflammation, apply topical antibiotics with or without topical steroids 1
• For mild to moderate inflammation without abscess, use high-potency topical corticosteroids alone or combined with topical antibiotics 1

Abscess Management

• Surgical drainage is mandatory if an abscess is present 1, 2
• Drainage options range from:
  • Using a hypodermic needle to lift the nail fold
  • Wide incision with a scalpel 1
• Oral antibiotics are usually not needed if adequate drainage is achieved, except in:
  • Immunocompromised patients
  • Severe infections 1, 2

Severity Classification

Acute paronychia can be categorized into three grades 1:

1. Grade 1 (Mild): Responds to conservative treatment
2. Grade 2 (Moderate): May require topical treatments
3. Grade 3 (Severe): Requires medical evaluation, possible surgical intervention or antibiotics

Chronic Paronychia Management

Chronic paronychia is defined by symptoms lasting at least six weeks and represents an irritant dermatitis to the breached nail barrier 1, 2.

Primary Interventions

• Identify and eliminate irritants (acids, alkalis, chemicals) commonly affecting housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 1, 2
• Apply high-potency topical corticosteroids (more effective than antifungals) 1
• Consider calcineurin inhibitors as an alternative 1, 2
• Apply topical antiseptics such as povidone-iodine 2% twice daily to the proximal part of the nail 1

For Fungal Involvement

• Itraconazole is recommended as first-line treatment at:
  • 200 mg per day, or
  • Pulse therapy (400 mg per day for 1 week each month) 1
• Fluconazole is an alternative if contraindications to itraconazole exist 1

Treatment Duration

• Treatment may take weeks to months, especially for chronic paronychia 1, 2
• Monitor for complications including:
  • Permanent nail deformity
  • Secondary infection
  • Permanent onycholysis 1

Special Considerations

High-Risk Patients

• Diabetic patients require more vigilant monitoring and earlier intervention 1
• Immunocompromised patients need special caution about infection risk 1
• EGFR-TKI-related paronychia (from cancer treatments) may require dose reduction or interruption of medication 1

When to Seek Medical Evaluation

Medical evaluation is necessary in cases of:

• Abscess formation
• Signs of spreading infection
• Systemic symptoms
• Immunocompromised status
• Failure to improve with home treatment 1

Prevention Strategies

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

Common Pitfalls to Avoid

• Do not use systemic antibiotics unless infection is proven 3
• Recognize that secondary bacterial or fungal superinfections can occur in up to 25% of acute paronychia cases 1
• Consider antifungal treatment if not responding to standard therapy 1
• Be aware that onychomycosis has high recurrence rates (40-70%) 1
• Chronic paronychia that is unresponsive to standard treatment should be investigated for unusual causes, including malignancy 4