What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should follow a severity-based approach, with first-line therapy consisting of warm water or vinegar soaks, topical 2% povidone-iodine, and high-potency topical corticosteroids for mild cases, progressing to oral antibiotics for moderate cases, and surgical drainage for severe cases with abscess formation. 1, 2

Classification and Assessment

• Evaluate severity based on parameters including redness, edema, discharge, and presence of granulation tissue 1
• Determine if the paronychia is acute (sudden onset, often with abscess) or chronic (lasting >6 weeks, representing irritant dermatitis) 3
• Check for presence of pus or abscess formation which would require drainage 2
• Assess for predisposing factors such as ingrown toenail (onychocryptosis), which may require specific management 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 2
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 2
• Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2

Grade 2 (Moderate) Paronychia

• Start oral antibiotics if signs of infection are present 2
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 4
• Consider silver nitrate chemical cauterization for excessive granulation tissue 4, 1

Grade 3 (Severe) Paronychia

• Swab any pus for culture and prescribe appropriate antibiotics 4
• Surgical drainage is mandatory for abscess formation 3
• Consider partial nail avulsion for severe cases, especially those associated with ingrown toenails 5

Special Considerations

For Chronic Paronychia

• Apply high-potency topical corticosteroids which have been found more effective than antifungals in chronic cases 6
• Consider intralesional triamcinolone acetonide for recalcitrant cases 2
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 4
• Address underlying causes such as frequent water exposure or chemical irritants 6

For Treatment Failures

• If initial treatment with cephalexin fails, consider switching to sulfamethoxazole-trimethoprim (Bactrim) which provides broader coverage including MRSA 7
• Obtain bacterial, viral, and fungal cultures to identify potential resistant organisms or non-bacterial causes, as secondary infections are present in up to 25% of cases 7
• Consider referral to dermatology or podiatry for recalcitrant cases 2

Prevention of Recurrence

• Keep hands and feet as dry as possible; avoid prolonged soaking in water 4, 2
• Avoid nail trauma/injury and cutting nails too short 4, 2
• Moisturize hands and feet regularly with emollients applied to cuticles and periungual tissues 4, 2
• Wear protective gloves during wet work or exposure to irritants 4
• Wear comfortable well-fitting shoes that protect nails without being restrictive 4

Common Pitfalls to Avoid

• Don't overlook potential secondary bacterial or mycological superinfections, which are present in up to 25% of cases 2
• Don't delay drainage of abscesses, which can lead to further tissue damage and spread of infection 3
• Don't neglect addressing underlying causes in chronic paronychia, such as occupational exposures or systemic conditions 6
• Don't continue ineffective antibiotics without obtaining cultures in non-responsive cases 7