From the Guidelines
Chronic paronychia treatment should prioritize topical antifungal medications, such as clotrimazole 1% or ketoconazole 2% cream, applied twice daily for 2-4 weeks, alongside lifestyle modifications to keep the affected area dry and avoid irritants, as recommended by the most recent guidelines 1.
Treatment Approach
The treatment of chronic paronychia involves a multifaceted approach that includes both medication and lifestyle changes.
- Topical antifungal medications are the mainstay of treatment, with options including clotrimazole 1% or ketoconazole 2% cream applied twice daily for 2-4 weeks.
- For cases with significant inflammation, a combination of antifungal and mild corticosteroid (like betamethasone valerate 0.1%) may be more effective.
- In severe or resistant cases, oral antifungals like fluconazole 150-300mg weekly for 2-6 weeks might be necessary.
- Bacterial superinfection should be treated with antibiotics such as clindamycin or amoxicillin-clavulanate for 7-10 days.
Lifestyle Modifications
Equally important to medication are lifestyle modifications that help prevent the recurrence of chronic paronychia.
- Keeping the affected area dry is crucial, as is avoiding irritants and minimizing water exposure by wearing cotton-lined waterproof gloves during wet work.
- Patients should avoid nail biting, finger sucking, and aggressive manicuring, as these behaviors can exacerbate the condition.
- Treatment success depends on addressing the underlying cause, whether it's repeated trauma, water exposure, or contact with irritants.
Underlying Cause
Chronic paronychia is often caused by Candida species and other fungi rather than bacteria, which explains why antifungals are the mainstay of treatment.
- The pathogenesis of paronychia involves the inhibition of the EGFR and downstream EGFR-dependent pathways in basal and suprabasal keratinocytes, leading to altered differentiation and migration of epidermal cells 1.
- Recovery typically takes weeks to months, and patients should continue preventive measures even after symptoms resolve to prevent recurrence.
Recent Guidelines
Recent guidelines, such as those from the Journal of the American Academy of Dermatology 1, emphasize the importance of symptom-directed management, including the use of topical 2% povidone-iodine, daily dilute vinegar soaks, and mid to high potency topical steroid ointment for edema and pain.
- These guidelines also recommend treating infection, stopping or avoiding topical steroids when necessary, and considering intralesional triamcinolone acetonide for recurrent or severe cases.
From the Research
Treatment Options for Chronic Paronychia
- General preventive measures form the cornerstone of therapy, as chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens 2, 3, 4
- Topical steroid creams have been found to be more effective in the treatment of chronic paronychia than systemic antifungals 2, 3
- Application of emollient lotions may be beneficial in treating chronic paronychia 3
- A combination of a broad-spectrum topical antifungal agent and a corticosteroid may be used to treat underlying inflammation and infection 3, 5
- In recalcitrant cases, surgical treatment may be resorted to, which includes en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal 2, 3
Management of Chronic Paronychia
- Patients should avoid exposure to contact irritants, such as acids, alkalis, and other chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 3, 4
- Treatment may take weeks to months, and patient education is paramount to reduce the recurrence of acute and chronic paronychia 4
- A new combination of topical medications, including an insulating polymer, topical antifungals, and a molecule with anti-inflammatory activity, may be effective in the treatment and prevention of moderate and chronic paronychia 5