Treatment Options for Paronychia
For effective management of paronychia, implement a stepwise approach starting with conservative measures for mild cases and progressing to more invasive interventions for severe or refractory cases. 1, 2
Classification and Initial Assessment
- Evaluate severity based on redness, edema, discharge, and granulation tissue 2
- Check for presence of pus or abscess formation which would require drainage 2
- Assess for predisposing factors such as ingrown toenail (onychocryptosis) 2
Prevention Measures
- Keep hands and feet as dry as possible 1
- Avoid prolonged soaking in soapy water without adequate protection 1
- Wear cotton gloves underneath washing up gloves when cleaning 1
- Trim nails carefully, ensuring they are straight and not too short 1, 2
- Apply emollients regularly to cuticles and periungual tissues 1, 2
- Wear comfortable, well-fitting shoes that protect nails without being restrictive 1
- Avoid nail trauma, injury, and skin irritants 1
Conservative Management (First-Line)
- For mild cases, implement antiseptic soaks with warm water for 15 minutes 3-4 times daily 1, 3
- White vinegar soaks (1:1 white vinegar:water) for 15 minutes daily 1, 3
- Apply topical 2% povidone iodine twice daily, which has shown benefit in controlled studies 1, 2
- Use high-potency topical corticosteroids alone or combined with topical antibiotics 1, 2
- Apply topical bacitracin 1-3 times daily to the affected area 4
- For chronic paronychia, regular application of emollients to cuticles and periungual tissues 1, 2
Antimicrobial Therapy
- For moderate to severe infection, oral antibiotics should be selected based on likely pathogens 2, 3
- Consider oral antibiotics if there are signs of spreading infection, though they have shown only anecdotal benefit 1, 3
- Be aware that secondary bacterial or mycological superinfections are present in up to 25% of cases 1, 2
- For suspected fungal infection, topical antifungals should be applied 2, 5
Interventional Management
- For paronychia with abscess formation, drainage is mandatory 3, 5
- Silver nitrate chemical cauterization for excessive granulation tissue 1
- For pyogenic granuloma, consider cryotherapy 1
- Topical timolol (0.5% gel, twice daily under occlusion for 1 month) has shown complete clearance in some cases 1
- For severe or refractory cases, surgical intervention may be necessary 1, 6
Grade-Based Management
Grade 1 (Mild)
- Continue conservative management with soaks and topical treatments 1
- Monitor closely as condition can escalate quickly 1
- Refer to dermatologist for further assessment if needed 1
Grade 2 (Moderate)
- Consider more aggressive treatment including oral antibiotics 1
- Apply combination of topical steroids, antifungals, antibiotics, and/or antiseptics 1
- Consult podiatrist for feet-related symptoms 1
Grade 3 (Severe)
- Refer for specialist support 1
- Swab any pus for culture and prescribe appropriate antibiotics 1
- Consider surgical intervention 1, 6
Special Considerations
- Chronic paronychia represents an irritant dermatitis and may require longer treatment duration (weeks to months) 3
- Common irritants include acids, alkalis, and chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 3
- Patient education is paramount to reduce recurrence of both acute and chronic paronychia 3
- For recurrent, severe, or treatment-refractory cases, consider intralesional triamcinolone acetonide 2