What is the best treatment for paronychia?

Best Treatment for Paronychia

The best 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 being the first-line treatment for acute paronychia, while chronic paronychia requires elimination of irritants and topical steroids. 1

Classification and Initial Assessment

Paronychia is an inflammatory condition affecting the nail folds and can be classified as:

1. Acute Paronychia:

   • Characterized by sudden onset, pain, redness, and swelling
   • Typically caused by polymicrobial infections after breach of protective nail barrier 2
   • Can be graded into three severity levels:
     • Grade 1 (Mild): Inflammation without abscess
     • Grade 2 (Moderate): Inflammation with abscess formation
     • Grade 3 (Severe): Extensive infection requiring urgent intervention 1

2. Chronic Paronychia:

   • Symptoms lasting at least six weeks
   • Represents an irritant dermatitis to the breached nail barrier 1, 2
   • Often associated with repeated exposure to moisture and irritants

Treatment Algorithm for Acute Paronychia

Step 1: Conservative Management (Grade 1)

• Warm soaks with or without Burow solution or 1% acetic acid for 15-20 minutes, 2-3 times daily 1, 2
• Avoid further trauma to the area
• Keep the area clean and dry between soaks

Step 2: For Persistent Inflammation without Abscess

• Topical antibiotics with or without topical steroids 1
• High-potency topical corticosteroids alone or combined with topical antibiotics for mild to moderate inflammation 1

Step 3: For Abscess Formation (Grade 2-3)

• 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
• Important: Oral antibiotics are usually not needed if adequate drainage is achieved, except in immunocompromised patients or severe infections 1

Treatment Algorithm for Chronic Paronychia

Step 1: Eliminate Causative Factors

• Identify and eliminate irritants such as acids, alkalis, and chemicals 1
• Common occupational exposures: housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 1, 2
• Keep hands dry and avoid prolonged water exposure 1

Step 2: Topical Treatments

• High-potency topical corticosteroids (more effective than antifungals) 1
• Calcineurin inhibitors as an alternative 1, 3
• Topical antiseptics such as povidone-iodine 2% twice daily to the proximal part of the nail 1

Step 3: For Fungal Involvement

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

Step 4: Refractory Cases

• Consider surgical options for recalcitrant cases:
  • En bloc excision of the proximal nail fold
  • Eponychial marsupialization, with or without nail plate removal 3
  • Swiss roll technique for severe cases 4

Special Considerations

• Immunocompromised patients: Lower threshold for oral antibiotics and more aggressive monitoring 1
• Diabetic patients: Require vigilant monitoring and earlier intervention due to increased infection risk 1
• Fungal involvement: May require additional antifungal treatment 1
• Malignancy: Consider investigation for unusual causes if chronic paronychia is unresponsive to standard treatment 5

Prevention Strategies

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

Follow-up Recommendations

• Follow-up within 1-2 weeks to ensure proper healing
• Return within 48-72 hours if signs of infection are present
• Monitor for complications including permanent nail deformity, secondary infection, and permanent onycholysis 1