What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should follow a stepwise approach based on severity, with initial management including warm water or vinegar soaks, topical antiseptics, and antibiotics for more severe cases. 1, 2

Classification and Assessment

• Paronychia is inflammation of the tissue surrounding the nail fold, which can be acute (infection-based) or chronic (irritant dermatitis) 2
• 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) 1

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

• Implement warm water soaks for 15 minutes 3-4 times daily or white vinegar soaks (1:1 white vinegar:water) for 15 minutes daily 3
• 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
• Consider potassium permanganate prophylactic soaks 3

Grade 2 (Moderate) Paronychia

• Continue topical treatments as in Grade 1 3
• Start oral antibiotics if signs of infection are present 3, 1
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 3
• Apply silver nitrate weekly by healthcare professional if over-granulation has developed 3
• Consult a podiatrist for feet-related symptoms 3

Grade 3 (Severe) Paronychia

• Swab any pus for culture and prescribe appropriate antibiotics 3
• Apply silver nitrate if over-granulation is present 3
• Consider surgical intervention for drainage or partial nail avulsion 3, 1
• Refer for specialist support (dermatology or podiatry) 3

Special Considerations

For Acute Paronychia

• If abscess is present, drainage is mandatory using techniques ranging from instrumentation with a hypodermic needle to a wide incision with a scalpel 2
• For pyogenic granuloma formation, consider scoop shave removal with hyfrecation or silver nitrate application 1

For Chronic Paronychia

• Identify and eliminate exposure to irritants (acids, alkalis, chemicals) 2, 4
• Apply high-potency topical corticosteroids which have been found more effective than antifungals in chronic cases 4
• For recalcitrant 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

• Keep hands and feet as dry as possible; avoid prolonged soaking in water 3
• Avoid nail trauma/injury and cutting nails too short 3, 1
• Moisturize hands and feet regularly with emollients applied to cuticles and periungual tissues 3, 1
• Wear protective gloves during wet work or exposure to irritants 1
• Wear comfortable well-fitting shoes that protect nails without being restrictive 3

Follow-up

• Reassess after 2 weeks of treatment 1
• If no improvement is seen, consider referral to dermatology or podiatry for further evaluation 1
• For chronic cases, be aware that treatment may take weeks to months 2

Common Pitfalls to Avoid

• Avoid using systemic antibiotics unnecessarily if adequate drainage is achieved, unless the patient is immunocompromised or has a severe infection 2
• Don't overlook potential secondary bacterial or mycological superinfections, which are present in up to 25% of cases 1
• Recognize that chronic paronychia is often a form of contact dermatitis rather than an infection, requiring different treatment approaches 4, 5
• Patients with chronic paronychia unresponsive to standard treatment should be investigated for unusual causes, such as malignancy 5