What are the management options for paronychia?

Management of Paronychia

The management of paronychia should include warm soaks with antiseptic solutions, topical antibiotics with steroids for inflammation, and surgical drainage if an abscess is present, with treatment approach varying based on whether the condition is acute or chronic. 1

Acute Paronychia Management

First-Line Treatment

• Warm soaks with or without Burow solution or 1% acetic acid (3-4 times daily for 15 minutes) 1, 2
• Dilute vinegar soaks (50:50 dilution) to nail folds twice daily as a non-antibiotic approach 1
• Mid to high-potency topical corticosteroid ointment for inflammation 1
• Topical antibiotics should be added when simple soaks don't relieve inflammation 2

When Abscess is Present

• Surgical drainage is mandatory for abscesses 1
• Drainage options include:
  • Simple instrumentation with a hypodermic needle
  • Wide incision with a scalpel
  • Intra-sulcal approach (preferable to nail fold incision) 3

Antibiotic Therapy

• Obtain culture before starting antibiotics to guide treatment 1
• Oral antibiotics are usually not needed if adequate drainage is achieved 2
• Exception: Immunocompromised patients or severe infections require oral antibiotics 1, 2
• Therapy should be based on most likely pathogens and local resistance patterns 2

Chronic Paronychia Management

Treatment Approach

• Identify and eliminate irritant exposure (acids, alkalis, chemicals) 1, 2, 4
• High-potency topical corticosteroids alone or combined with topical antibiotics 1
• Topical calcineurin inhibitors as an alternative to steroids 2, 4
• For fungal involvement:
  • Topical antifungals (imidazoles) 1
  • Oral fluconazole for Candida species 1
  • Itraconazole for resistant cases (more effective than terbinafine) 1

Surgical Options for Recalcitrant Cases

• En bloc excision of the proximal nail fold
• Eponychial marsupialization (with or without nail plate removal) 4
• Swiss roll technique for severe cases 5

Special Considerations

High-Risk Patients

• Diabetic patients:

  • Require more vigilant monitoring and earlier intervention 1
  • Keep the area dry to prevent further infection 1
  • Lower threshold for systemic therapy

• Immunocompromised patients:

  • Lower threshold for oral antibiotics 1
  • More aggressive treatment approach 1
  • Closer follow-up recommended

Prevention Strategies

• Keep hands and feet dry, avoid prolonged water exposure 1
• Wear gloves while cleaning or doing wet work 1
• Apply daily topical emollients to cuticles and periungual tissues 1
• Proper nail trimming (straight across rather than curved) 1
• File nail surfaces with an emery board after softening in warm water 1
• Consider urea-based cream to reduce nail thickness for recurrent cases 1

Follow-up and Monitoring

• Regular follow-up every 2-4 weeks until resolution 1
• Return within 48-72 hours if signs of infection worsen 1
• Monitor for complications:
  • Permanent nail deformity
  • Secondary infection
  • Permanent onycholysis 1

When to Seek Medical Evaluation

• Abscess formation
• Signs of spreading infection
• Systemic symptoms (fever)
• Immunocompromised status
• Failure to improve with home treatment 1
• Unusual or persistent cases should be investigated for malignancy 3