What is the treatment for paronychia?

Treatment of Paronychia

The most effective treatment for paronychia includes warm soaks with antiseptic solutions, topical antibiotics with steroids for inflammation, and surgical drainage if an abscess is present. 1, 2

Classification and Initial Approach

Acute Paronychia

• Characterized by sudden onset, pain, swelling, and erythema around the nail fold
• Typically caused by polymicrobial infections after breach of protective nail barrier 2
• Treatment approach:

1. First-line treatment:

   • Warm water soaks (with or without Burow solution or 1% acetic acid) 3-4 times daily 2
   • Vinegar soaks with 50:50 dilution applied to nail folds twice daily 1
   • Keep the affected area clean and dry between soaks

2. For mild to moderate inflammation without abscess:

   • Apply high-potency topical corticosteroids alone or combined with topical antibiotics 2-3 times daily 1
   • Topical antiseptics such as 2% povidone-iodine applied twice daily 1

3. When abscess is present:

   • Surgical drainage is mandatory 1, 2
   • Drainage options range from using a hypodermic needle to lift the nail fold to a wide incision with a scalpel 1
   • Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or has a severe infection 2

Chronic Paronychia

• Symptoms lasting at least six weeks 2
• Represents an irritant dermatitis to the breached nail barrier
• Treatment approach:

1. Address underlying causes:

   • Identify and eliminate irritants (acids, alkalis, chemicals) 2
   • Keep hands and feet as dry as possible 1

2. Medication therapy:

   • High-potency topical corticosteroids alone or combined with topical antibiotics 1
   • Alternative: calcineurin inhibitors for a steroid-sparing approach 1
   • For fungal involvement: topical antifungals (like octopirox and climbazole) 3

3. For resistant cases:

   • More aggressive techniques to restore the protective nail barrier 2
   • Consider Swiss roll technique for severe cases 4
   • Dermatology consultation for suspected chronic paronychia 5

Special Interventions

Mechanical Interventions

• Gutter splinting using a flexible tube placed on the lateral edge of the nail 1
• Taping the nail fold away from the nail plate 1
• Silver nitrate application for over-granulation tissue 6, 1
• Partial nail avulsion with phenolization for recurrent cases 1

For Specific Populations

• Diabetic patients: More vigilant monitoring and earlier intervention due to increased infection risk 1
• Immunocompromised patients: Lower threshold for oral antibiotics and more aggressive treatment 1, 2

Prevention Strategies

• Proper nail trimming: cut nails straight across and not too short 1
• Avoid trauma and minimize repetitive friction to the nail area 1
• Keep hands and feet dry; avoid prolonged soaking in water 6, 1
• Apply daily topical emollients to cuticles and periungual tissues 1
• Wear gloves while cleaning or doing wet work 1
• Regular follow-up every 2-4 weeks until resolution for chronic cases 1

Common Pitfalls to Avoid

1. Failure to drain an abscess: This is the most common mistake in acute paronychia management. Always assess for fluctuance and drain if present.

2. Overuse of oral antibiotics: Oral antibiotics are usually unnecessary if adequate drainage is achieved in immunocompetent patients 2

3. Neglecting underlying causes in chronic paronychia: Treatment will fail if irritants or contributing factors are not addressed 2

4. Inadequate follow-up: Monitor for complications including permanent nail deformity, secondary infection, and permanent onycholysis 1

5. Missing serious underlying conditions: Investigate for unusual causes such as malignancy in cases unresponsive to standard treatment 5