What are the management options for paronychia?

Management of Paronychia

The management of paronychia should focus on warm soaks with antiseptic solution, topical treatments including corticosteroids, and surgical drainage for abscesses, with treatment approach varying based on whether the condition is acute or chronic. 1

Classification and Diagnosis

• Acute paronychia: Characterized by sudden onset of inflammation, pain, erythema, and possible abscess formation, typically caused by polymicrobial infections after breach of the protective nail barrier 2
• Chronic paronychia: Defined as symptoms lasting at least six weeks, representing an irritant dermatitis to the breached nail barrier 2, 3

Management of Acute Paronychia

Conservative Management

1. Warm soaks with antiseptic solution

   • Soak the affected digit in warm, soapy water for 10-15 minutes, 2-3 times daily 1
   • Alternative: Dilute vinegar soaks (50:50 dilution) twice daily as a non-antibiotic approach 1

2. Topical treatments

   • Mid- to high-potency topical corticosteroid ointment to reduce inflammation 1
   • Topical antibiotics with steroids when simple soaks don't relieve inflammation 2

3. Separation techniques

   • Placing cotton wisps or dental floss under the ingrown nail edge to relieve pressure 1

Surgical Interventions

1. Abscess drainage

   • Mandatory for abscesses 1
   • Options range from using a hypodermic needle to a wide incision with a scalpel 2
   • Intra-sulcal approach is preferable to nail fold incision 4

2. Partial nail avulsion

   • For more severe cases or when conservative management fails 1
   • Involves removing the detached or ingrown portion of the nail plate 1

3. Swiss roll technique

   • For severe acute paronychia 5
   • Exposes the inflamed germinal matrix to permit unrestricted drainage 5

Antibiotic Therapy

• Oral antibiotics usually not needed if adequate drainage is achieved 2
• Consider oral antibiotics for:
  • Immunocompromised patients 1, 2
  • Severe infections 2
  • Diabetic patients (who require more vigilant monitoring) 1

Management of Chronic Paronychia

Conservative Management

1. Eliminate irritants

   • Identify and avoid exposure to irritants (acids, alkalis, chemicals) 2, 3
   • Keep hands and feet dry, avoid prolonged water exposure 1
   • Wear gloves while cleaning or doing wet work 1

2. Topical treatments

   • Mid- to high-potency topical corticosteroids (more effective than antifungals) 1, 3
   • Calcineurin inhibitors as an alternative 2
   • Daily topical emollients to cuticles and periungual tissues 1

3. Antifungal therapy

   • Topical antifungals (imidazoles) for fungal involvement 1
   • Oral fluconazole for Candida species 1
   • Itraconazole for resistant cases 1

Surgical Interventions

1. For recalcitrant cases:
   • En bloc excision of the proximal nail fold 3
   • Eponychial marsupialization, with or without nail plate removal 3

Special Considerations

Diabetic Patients

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

Immunocompromised Patients

• More aggressive treatment approach 1
• Lower threshold for oral antibiotics 1

Prevention

• Proper nail care: trim nails straight across, file nail surfaces, keep nails short and clean 1
• Wear shoes with adequate toe box width, avoid high heels and pointed shoes 1
• Apply daily topical emollients to cuticles and periungual tissues 1
• Patient education is paramount to reduce recurrence 2

Follow-up

• Regular follow-up every 2-4 weeks until resolution 1
• Return immediately if signs of infection develop 1
• For chronic paronychia, treatment may take weeks to months 2
• Monitor for complications: permanent nail deformity, secondary infection, onycholysis 1