What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should include warm soaks with antiseptic solution, topical antibiotics with steroids for inflammation, and surgical drainage if an abscess is present. 1

Types and Causes

Paronychia is an inflammation of the tissue surrounding the nail fold that can be classified as:

• Acute paronychia: Typically caused by polymicrobial bacterial infections (commonly Staphylococcus aureus or Streptococcus) after the protective nail barrier has been breached 2
• Chronic paronychia: Characterized by symptoms lasting at least six weeks, representing an irritant dermatitis to the breached nail barrier 2

Treatment Algorithm

Acute Bacterial 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 without abscess:

   • Topical antibiotics with steroids to address both infection and inflammation 1
   • High-potency topical corticosteroids alone or combined with topical antibiotics 1

3. If abscess is present:

   • Surgical drainage is mandatory 1
   • Drainage options range from using a hypodermic needle to a wide incision with a scalpel 2
   • Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or has a severe infection 2

Chronic Paronychia

1. Address underlying causes:

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

2. Topical treatments:

   • Topical steroids are more effective than antifungals for chronic paronychia 3
   • Apply mid- to high-potency topical corticosteroid ointment for inflammation 1
   • For fungal involvement, add topical antifungals (imidazoles) 1

3. For resistant cases:

   • Oral fluconazole for Candida species in fungal paronychia 1
   • Itraconazole for resistant fungal cases 1

4. Surgical options for recalcitrant cases:

   • En bloc excision of the proximal nail fold or eponychial marsupialization 3
   • Partial nail avulsion for associated ingrown toenails 1

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

Prevention

• Proper nail care: trim nails straight across, file nail surfaces after softening in warm water 1
• Apply daily topical emollients to cuticles and periungual tissues 1
• Wear shoes with adequate toe box width; avoid high heels and pointed shoes 1
• Keep hands and feet dry when possible 1

Follow-up

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

Common Pitfalls to Avoid

1. Overuse of oral antibiotics: Systemic antibiotics are usually unnecessary if adequate drainage is achieved in acute paronychia 2
2. Neglecting the underlying cause: Chronic paronychia will recur if irritants or predisposing factors are not addressed 3
3. Delayed drainage: Failure to drain an abscess promptly can lead to worsening infection and complications 1
4. Missing fungal involvement: Chronic paronychia may have secondary fungal colonization requiring specific antifungal treatment 4

Remember that patient education about prevention and proper nail care is paramount to reduce the recurrence of both acute and chronic paronychia 2.