What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should focus on warm soaks with antiseptic solution, topical corticosteroids for inflammation, surgical drainage for abscesses, and specific antimicrobial therapy based on whether the condition is acute bacterial or fungal in nature. 1

Distinguishing Acute vs. Chronic Paronychia

• Acute paronychia: Polymicrobial infection after nail barrier breach, typically presenting with sudden onset pain, redness, swelling, and possible abscess formation 2
• Chronic paronychia: Symptoms lasting at least six weeks, representing irritant dermatitis to the breached nail barrier 2, 3

Treatment Algorithm for Acute Paronychia

1. First-line treatment:

   • Warm soaks with antiseptic solution for 10-15 minutes, 2-3 times daily 1
   • Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily as a non-antibiotic approach 1

2. For inflammation:

   • Mid to high-potency topical corticosteroid ointment 1
   • Can be combined with topical antibiotics when simple soaks don't relieve inflammation 2

3. If abscess is present:

   • Surgical drainage is mandatory 1
   • Drainage options range from using a hypodermic needle to wide incision with a scalpel 2
   • Intra-sulcal approach is preferable to nail fold incision 4

4. Topical antibiotics:

   • For mild cases, apply mupirocin ointment to affected area three times daily 5
   • Re-evaluate patients not showing clinical response within 3-5 days 5

5. Oral antibiotics:

   • Usually not needed if adequate drainage is achieved 2
   • Consider for immunocompromised patients or severe infections 1, 2

Treatment for Chronic Paronychia

1. Primary approach:

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

2. Topical therapy:

   • 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. For fungal involvement:

   • Topical antifungal agents (imidazoles) 1
   • Oral fluconazole for Candida species 1
   • Itraconazole for resistant cases 1

4. Surgical options for recalcitrant cases:

   • En bloc excision of proximal nail fold 3
   • Eponychial marsupialization, with or without nail plate removal 3
   • Swiss roll technique for chronic and severe acute paronychia 6

Special Considerations

• Diabetic patients: Require more vigilant monitoring and earlier intervention due to increased infection risk 1
• Immunocompromised patients: Lower threshold for oral antibiotics and more aggressive treatment 1
• Monitoring: Regular follow-up every 2-4 weeks until resolution 1
• Warning signs: Return within 48-72 hours if signs of infection develop 1
• Complications: Monitor for permanent nail deformity, secondary infection, and permanent onycholysis 1
• Severe cases: Watch for progression to osteomyelitis, especially with chronic paronychia 7

Prevention Measures

• Proper nail care: trim nails straight across, file surfaces after softening in warm water 1
• 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

Treatment may take weeks to months, particularly for chronic paronychia. Patient education is essential to reduce recurrence of both acute and chronic paronychia 2, 3.