What antibiotic is recommended for the treatment of paronychia?

Antibiotic Treatment for Paronychia

For paronychia treatment, topical povidone iodine 2% applied twice daily is the first-line antimicrobial therapy, with oral antibiotics reserved for cases with suspected infection or those not responding to topical treatment. 1

Classification and Initial Assessment

• Paronychia is an inflammation of the tissue folds surrounding the nail (proximal and/or lateral nail folds) 2
• Can be classified as:
  • Acute paronychia: Primarily caused by bacterial infection (commonly Staphylococcus aureus or Streptococcus) 2
  • Chronic paronychia: Lasting at least six weeks, representing an irritant dermatitis with secondary bacterial or fungal colonization 3

Treatment Algorithm Based on Severity

Grade 1 (Mild) Paronychia

• Continue monitoring for changes in severity 1
• Apply topical povidone iodine 2% twice daily 1, 4
• Consider topical antibiotics with corticosteroids 1
• Reassess after 2 weeks; if worsening or not improving, proceed to next step 1

Grade 2 (Moderate) Paronychia

• Continue monitoring for severity changes 1
• Apply topical povidone iodine 2% 1
• Consider topical beta-blocking agents (timolol 0.5% gel twice daily under occlusion) 1
• Add topical antibiotics with corticosteroids 1
• If infection is suspected: Obtain bacterial/viral/fungal cultures 1
• Add oral antibiotics if signs of infection are present 1, 3
• Reassess after 2 weeks; if worsening or not improving, proceed to next step 1

Grade 3 (Severe) or Intolerable Grade 2 Paronychia

• Interrupt causative agents if applicable 1
• Obtain bacterial/viral/fungal cultures if infection is suspected 1
• Apply topical povidone iodine 2% 1
• Consider topical beta-blocking agents 1
• Add topical antibiotics with corticosteroids 1
• Add oral antibiotics 1
• Consider partial nail avulsion for severe cases 1
• Reassess after 2 weeks 1

Antibiotic Selection

Topical Antibiotics

• Combination products with antibiotics and corticosteroids are preferred for initial treatment 1, 3

Oral Antibiotics (when indicated)

• First-line: Anti-staphylococcal penicillins (flucloxacillin, dicloxacillin) for MSSA infections 5
• Alternatives (for penicillin allergy or treatment failure):
  • First-generation cephalosporins (cephalexin) 5
  • Clindamycin 5
  • If MRSA is suspected: Sulfamethoxazole-trimethoprim (Bactrim) 4

Important Considerations

• Secondary bacterial or mycological superinfections are present in up to 25% of paronychia cases 1, 4
• Both gram-positive and gram-negative organisms have been implicated in paronychia 1
• Avoid systemic antibiotics unless infection is proven 2
• If paronychia worsens on cephalexin, consider switching to sulfamethoxazole-trimethoprim for broader coverage 4
• For chronic paronychia, treatment should focus on removing irritants and managing inflammation rather than antibiotics 3

Prevention Measures

• Gentle skin care and hand protection 1
• Avoid repeated friction, trauma, and excessive pressure 1
• Wear gloves while cleaning or working with water/chemicals 1, 4
• Avoid biting nails or cutting nails too short 1
• Regular use of antimicrobial soaks 1
• Daily application of topical emollients to cuticles and periungual tissues 1, 4
• Wear comfortable shoes with adequate toe space 1

Follow-up

• Reassess after 2 weeks of treatment 1, 4
• If no improvement is seen, consider referral to dermatology or hand surgery 4
• For chronic cases, treatment may take weeks to months 3