What is the recommended treatment for paronychia?

Treatment of Paronychia

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

Acute Paronychia Management

Initial Treatment

• Warm soaks with or without Burow solution or 1% acetic acid for 15-20 minutes, 2-3 times daily 1, 2
• Topical antibiotics with or without topical steroids if simple soaks don't relieve inflammation 1
• High-potency topical corticosteroids alone or combined with topical antibiotics for mild to moderate inflammation without abscess 1

Abscess Management

• Surgical drainage is mandatory if an abscess is present 1, 2
• Drainage options include:
  • Using a hypodermic needle to lift the nail fold
  • Wide incision with a scalpel 1, 2
• Intra-sulcal approach is preferable to a nail fold incision for surgical drainage 3

Antibiotic Therapy

• Oral antibiotics are usually not needed if adequate drainage is achieved 1, 2
• Exceptions for oral antibiotics include:
  • Immunocompromised patients
  • Severe infections 1
• When needed, antibiotic therapy should be based on most likely pathogens and local resistance patterns 2

Chronic Paronychia Management

Primary Interventions

• Identify and eliminate irritants (acids, alkalis, chemicals) 1, 2
• Common irritant exposures: housekeepers, dishwashers, bartenders, florists, bakers, swimmers 1, 4
• High-potency topical corticosteroids (more effective than antifungals) 1, 4
• Calcineurin inhibitors as an alternative to steroids 1, 4
• Topical antiseptics such as povidone-iodine 2% twice daily to the proximal nail 1

For Fungal Involvement

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

Refractory Cases

• More aggressive techniques may be required to restore the protective nail barrier 2
• 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

Prevention Strategies

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

Follow-up and Monitoring

• Follow-up within 1-2 weeks to ensure proper healing 1
• Return within 48-72 hours if signs of infection are present 1
• Monitor for complications:
  • Permanent nail deformity
  • Secondary infection
  • Permanent onycholysis 1

Special Considerations

• Diabetic patients require more vigilant monitoring and earlier intervention 1
• Immunocompromised patients need more aggressive management due to increased infection risk 1
• Patients with chronic paronychia unresponsive to standard treatment should be investigated for unusual causes, including malignancy 3