What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should follow a graded approach based on severity, with first-line management including antiseptic soaks, topical antimicrobials, and anti-inflammatory agents, progressing to oral antibiotics and surgical intervention for more severe cases. 1

Classification and Initial Assessment

• Paronychia is an inflammatory disorder of the nail folds presenting as redness, tenderness, and swelling 2
• Evaluate severity based on parameters including redness, edema, discharge, and presence of 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) 1

Conservative Management (First-Line)

For Acute Paronychia:

• Implement antiseptic soaks with dilute vinegar (1:1 white vinegar:water) for 15 minutes daily 3, 1
• Warm water soaks for approximately 15 minutes 3-4 times per day can be beneficial 3, 4
• Apply topical 2% povidone-iodine twice daily to the affected area 1
• Use mid to high potency topical steroids to nail folds twice daily to reduce inflammation 1
• Apply topical antiseptics and antibiotics as necessary 3

For Chronic Paronychia:

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 3, 1
• Regular application of emollients to cuticles and periungual tissues 3, 1
• Potassium permanganate prophylactic soaks may be beneficial 3

Antimicrobial Therapy

• For moderate to severe infection, oral antibiotics should be selected based on likely pathogens 1
• If initial treatment fails, consider broader spectrum antibiotics that cover MRSA 1
• Swab any pus for culture and prescribe appropriate antibiotics based on results 3
• Be aware that secondary bacterial or fungal superinfections are present in up to 25% of paronychia cases 1

Surgical Interventions

• For paronychia with abscess formation, drainage is mandatory 4
• Options for drainage range from using a hypodermic needle to a wide incision with a scalpel 4
• For paronychia with onychocryptosis (ingrown toenail), use techniques such as dental floss to separate the lateral nail edge from underlying tissue 1
• Silver nitrate chemical cauterization is recommended for excessive granulation tissue 3, 1
• For severe cases, consider surgical treatment including en bloc excision of the proximal nail fold or eponychial marsupialization 2, 5

Special Considerations

• For pyogenic granuloma formation, scoop shave removal with hyfrecation or silver nitrate application is recommended 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 3
• For EGFR TKI-associated paronychia, treatment should be graded according to severity:
  • Grade 1: Continue medication with topical treatments 3
  • Grade 2: Consider dose reduction/interruption and add oral antibiotics 3
  • Grade 3: Discontinue medication temporarily and refer for specialist support 3

Prevention of Recurrence

• Keep feet and hands as dry as possible 3
• Avoid nail trauma/injury and cutting nails too short 3
• Moisturize hands and feet regularly 3
• Wear comfortable well-fitting shoes and cotton socks 3
• Use protective gloves during activities involving water or chemicals 3, 1
• Wear cotton gloves underneath washing up gloves to protect hands 3

Follow-up

• Reassess after 2 weeks of treatment 1
• If no improvement is seen, consider referral to dermatology or podiatry 1
• For chronic paronychia, be aware that treatment may take weeks to months 4
• Patient education is paramount to reduce recurrence of acute and chronic paronychia 4

Pitfalls and Caveats

• Failure to drain an abscess when present will lead to treatment failure 4
• Chronic paronychia unresponsive to standard treatment should be investigated for unusual causes, including malignancy 6
• Avoid prolonged antibiotic use without drainage when an abscess is present 4
• Recognize that chronic paronychia is often a form of contact dermatitis rather than an infection 6
• Early intervention is crucial as grade 1 paronychia can escalate to grade 2 very quickly 3