How is paronychia treated?

Treatment of Paronychia

The management of paronychia should include topical treatments such as 2% povidone-iodine or dilute vinegar soaks for mild cases, with progression to oral antibiotics for more severe or treatment-resistant cases, and surgical intervention for cases with abscess formation or significant granulation tissue. 1

Types of Paronychia

Paronychia is an inflammation of the tissue surrounding the nail, which can be classified as:

• Acute paronychia: Characterized by painful erythematous inflammation with swelling and tenderness of the lateral nail folds, typically caused by bacterial infection after breach of the protective nail barrier 1, 2

• Chronic paronychia: Represents an irritant dermatitis to the breached nail barrier, lasting at least six weeks, where the cuticle becomes detached from the nail plate, allowing microorganisms to enter 3, 2

Diagnostic Approach

• Obtain bacterial/viral/fungal cultures if infection is suspected, particularly in cases not responding to initial therapy 1
• Secondary bacterial or mycological superinfections are present in up to 25% of cases 1, 3
• Both gram-positive and gram-negative organisms have been implicated 1

Treatment Algorithm Based on Severity

Grade 1 (Mild) Paronychia

• First-line treatment:
  • Topical 2% povidone-iodine applied twice daily 1
  • Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily for 10-15 minutes 1
  • Mid to high potency topical steroid ointment to nail folds twice daily 1

Grade 2 (Moderate) Paronychia

• Continue with Grade 1 treatments plus:
  • Topical antibiotics and corticosteroids 1
  • Oral antibiotics if not responding to topical treatment 1
  • For onychocryptosis (ingrown nail): dental floss insertion under the ingrown nail or splinting by flexible tube 1

Grade 3 (Severe) or Intolerable Grade 2 Paronychia

• Treatment options:
  • Interrupt causative factors until improvement to Grade 0/1 1
  • Oral antibiotics 1
  • Consider partial nail avulsion for severe cases 1
  • For granulation tissue: scoop shave removal + hyfrecation or silver nitrate application 1
  • For recurrent, severe, or treatment-refractory cases: doxycycline 100 mg twice daily for one month 1

Preventive Measures

Patient education with preventive measures should be systematically promoted 1, 3:

• Gentle skin care
• Preventive correction of nail curvature with referral to a podiatrist if needed
• Avoidance of repeated friction, trauma, and excessive pressure
• Wearing gloves while cleaning
• Avoiding biting nails or cutting nails too short
• Regular trimming of nails ensuring they are straight and not too short
• Daily application of topical emollients to cuticles and periungual tissues
• Wearing comfortable well-fitting shoes and cotton socks

Special Considerations

• For chronic paronychia, treatment is aimed at stopping the source of irritation while treating inflammation with topical steroids or calcineurin inhibitors 2
• For drug-induced paronychia (e.g., from anticancer agents), topical timolol (0.5% gel, twice daily under occlusion for 1 month) has shown benefit 1
• Surgical drainage is indicated when abscess is present 2
• Treatment may take weeks to months, especially for chronic cases 2

Common Pitfalls to Avoid

• Do not use systemic antibiotics unless infection is proven 4
• Do not rely solely on clinical appearance for diagnosis; obtain cultures when appropriate 1
• Avoid prolonged immersion in water, which can worsen chronic paronychia 3
• Do not ignore underlying conditions that may predispose to paronychia, such as diabetes or immunosuppression 1
• Recognize that chronic paronychia unresponsive to standard treatment should be investigated for unusual causes, including malignancy 5