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, and surgical drainage if an abscess is present, with specific approaches varying based on whether the condition is acute or chronic. 1

Classification and Diagnosis

Paronychia is inflammation of the nail folds and can be classified as:

• Acute paronychia: Sudden onset, typically caused by polymicrobial infections after nail barrier breach 2
• Chronic paronychia: Symptoms lasting at least six weeks, representing an irritant dermatitis to the breached nail barrier 2

Treatment Algorithm for Acute Paronychia

First-Line Treatment

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

For Abscess Formation

• Surgical drainage is mandatory if an abscess is present 1
• Drainage options include:
  • Simple elevation of the nail fold using a 21G or 23G needle 3
  • Wider incision with a scalpel for larger abscesses 2

For Severe or Resistant Cases

• Oral antibiotics may be necessary for immunocompromised patients or severe infections 2
• For fungal involvement: Topical antifungals (imidazoles) 1
• For Candida species: Oral fluconazole 1
• For resistant fungal cases: Itraconazole is more effective than terbinafine 1

Treatment Algorithm for Chronic Paronychia

First-Line Treatment

• Mid to high-potency topical corticosteroid ointment for inflammation 1
• Elimination of irritant exposure (crucial for long-term success) 2
• Topical calcineurin inhibitors as an alternative to steroids 2

For Persistent Cases

• Combination therapy with topical antifungals (octopirox and climbazole) plus anti-inflammatory agents 4
• Surgical options for recalcitrant cases:
  • En bloc excision of the proximal nail fold
  • Eponychial marsupialization (with or without nail plate removal) 5

Special Considerations

For Diabetic Patients

• More vigilant monitoring and earlier intervention due to increased infection risk 1
• Keep the area dry to prevent further infection 1
• Lower threshold for oral antibiotics 1

For Immunocompromised Patients

• More aggressive treatment approach with earlier use of oral antibiotics 1
• Closer follow-up to monitor for complications 1

Preventive Measures

• Proper nail care: Trimming nails straight across and filing nail surfaces 1
• Avoid prolonged water exposure and wear gloves while cleaning or doing wet work 1
• Apply daily topical emollients to cuticles and periungual tissues 1
• Avoid nail trauma and artificial nails 2

Follow-Up Recommendations

• Regular follow-up every 2-4 weeks until resolution 1
• Return within 48-72 hours if signs of infection develop 1
• Monitor for complications including permanent nail deformity, secondary infection, and permanent onycholysis 1

Common Pitfalls to Avoid

1. Failing to drain an abscess when present, which can lead to worsening infection
2. Overlooking fungal or mixed infections in chronic paronychia
3. Not addressing underlying causes in chronic cases (occupational exposures, etc.)
4. Inadequate patient education about preventive measures, which is crucial for preventing recurrence 2
5. Underestimating infection risk in diabetic or immunocompromised patients 1