What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia primarily consists of warm soaks with antiseptic solutions (such as 2% povidone-iodine), topical antibiotics with steroids for inflammation, and surgical drainage if an abscess is present. 1

Acute Paronychia Treatment Algorithm

Initial Management

• Warm soaks with antiseptic solutions:

  • 2% povidone-iodine solution
  • Alternatively, Burow solution or 1% acetic acid 2
  • Apply for 15 minutes, 3-4 times daily

• For mild to moderate inflammation without abscess:

  • Topical antibiotics with or without steroids if soaks don't relieve inflammation 1
  • High-potency topical corticosteroids alone or combined with topical antibiotics 1

If Abscess is Present

• Surgical drainage is mandatory 1, 2

  • Options include:
    • Simple drainage using a hypodermic needle
    • Incision and drainage with a scalpel
    • Intra-sulcal approach is preferable to nail fold incision for toenail paronychia 3

• Oral antibiotics:

  • Usually not needed if adequate drainage is achieved 1, 2
  • Consider for:
    • Immunocompromised patients
    • Severe infections
    • Diabetic patients (require more vigilant monitoring) 1
  • Clindamycin may be considered for severe infections 1

Chronic Paronychia Treatment

First-Line Approach

• Address underlying causes:

  • Avoid irritants and excessive moisture 1
  • Wear gloves while cleaning or doing wet work 1

• Medication therapy:

  • High-potency topical corticosteroids alone or combined with topical antibiotics 1
  • Calcineurin inhibitors as a steroid-sparing alternative 1, 2

For Resistant Cases

• Antifungal therapy:

  • Itraconazole is more effective than terbinafine 1

• Surgical options for recalcitrant cases:

  • En bloc excision of the proximal nail fold
  • Eponychial marsupialization
  • Swiss roll technique for severe cases 4

Special Considerations

For Ingrown Nails with Paronychia

• Conservative measures:

  • Vinegar soaks (50:50 dilution) applied to nail folds twice daily 1
  • Gutter splinting using a flexible tube 1
  • Taping the nail fold away from the nail plate 1

• Definitive treatment:

  • Partial nail avulsion with phenolization is most effective for preventing recurrence 1

Prevention Strategies

• Keep hands and feet dry
• Avoid prolonged water exposure
• Apply daily topical emollients to cuticles
• Proper nail trimming to avoid trauma 1

Common Pitfalls to Avoid

• Failure to drain an abscess when present
• Overuse of oral antibiotics when not necessary
• Neglecting underlying causes in chronic paronychia
• Inadequate follow-up (should be every 2-4 weeks until resolution) 1
• Missing serious underlying conditions in immunocompromised patients 1

When to Seek Medical Evaluation

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

The treatment approach should be tailored based on whether the paronychia is acute or chronic, as they represent different pathophysiological processes. Acute paronychia is typically a polymicrobial infection requiring antimicrobial therapy and possible drainage, while chronic paronychia represents an irritant dermatitis requiring elimination of irritants and anti-inflammatory treatment 2, 5.