What is the management of paronychia of the toenail?

Management of Paronychia of the Toenail

The management of toenail paronychia should follow a stepwise approach beginning with conservative measures such as antiseptic soaks and topical treatments, progressing to oral antibiotics for infection, and surgical intervention for severe or refractory cases. 1

Initial Assessment and Classification

• Determine if the paronychia is acute (sudden onset, typically infectious) or chronic (lasting >6 weeks, often irritant dermatitis) 2, 3
• Evaluate severity based on parameters including redness, edema, discharge, and granulation tissue 1
• Check for presence of pus or abscess formation which would require drainage 1
• Assess for predisposing factors such as ingrown toenail (onychocryptosis), which may require specific management 1, 3

Conservative Management (First-Line)

For Acute Paronychia:

• Implement antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 1
• Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1
• If there is evidence of infection, obtain cultures before starting antimicrobial therapy 4

For Chronic Paronychia:

• Identify and eliminate irritants and moisture exposure 5
• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 1
• Consider topical calcineurin inhibitors as an alternative to steroids for long-term management 5
• Regular application of emollients to cuticles and periungual tissues 1

Antimicrobial Therapy

• For mild to moderate infection without abscess, topical antibiotics may be sufficient 2
• For moderate to severe infection, oral antibiotics should be selected based on likely pathogens 6
• If initial treatment with cephalexin fails, consider switching to sulfamethoxazole-trimethoprim (Bactrim) which provides broader coverage including MRSA 6
• Be aware that secondary bacterial or mycological superinfections are present in up to 25% of paronychia cases 6, 4

Surgical Interventions

• For paronychia with abscess: drainage is mandatory using techniques ranging from needle aspiration to incision with a scalpel 2
• For paronychia with onychocryptosis (ingrown toenail):
  • Dental floss nail technique to separate the lateral nail edge from underlying tissue 1
  • Splinting by flexible tube placement on the lateral edge of the nail 1
  • Cotton packing/cast edge separation 1
• For severe or recurrent cases:
  • Silver nitrate chemical cauterization for excessive granulation tissue 1
  • Partial nail avulsion may be necessary in severe cases 3
  • Consider "Swiss roll technique" for chronic and severe acute paronychia 7

Special Considerations

• For pyogenic granuloma formation: scoop shave removal with hyfrecation or silver nitrate application 1
• For recurrent, severe, or treatment-refractory cases: consider intralesional triamcinolone acetonide 1
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 1

Prevention of Recurrence

• Gentle nail care: trim nails straight across and not too short 1
• Avoid repeated friction, trauma, and excessive pressure 1
• Wear comfortable well-fitting shoes and cotton socks 1
• Use protective gloves during activities involving water or chemicals 4
• Regular monitoring for early symptoms to prevent progression 1

Follow-up

• Reassess after 2 weeks of treatment 6, 4
• If no improvement is seen, consider referral to dermatology or podiatry for further evaluation 4
• For chronic cases, patient education is paramount as treatment may take weeks to months 2