What is the recommended treatment for paronychia?

Treatment of Paronychia

The recommended treatment for paronychia includes antiseptic soaks, topical povidone iodine 2% twice daily, topical corticosteroids, and oral antibiotics for more severe cases, with surgical drainage indicated for abscess formation. 1, 2

Classification and Initial Assessment

• Paronychia is an inflammatory process involving the soft tissues around the nail that can be classified as acute (infection-related) or chronic (irritant dermatitis) 3
• Assess severity based on redness, edema, discharge, and granulation tissue 1, 2
• Check for presence of abscess formation which would require drainage 2
• Secondary bacterial or mycological superinfections are present in up to 25% of cases 1, 2

Treatment Algorithm for Acute Paronychia

First-Line Treatment

• Implement warm antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 2, 3
• 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 2

For Moderate to Severe Infection

• Oral antibiotics should be prescribed based on likely pathogens 2
• If initial treatment with cephalexin fails, consider switching to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 4
• Reassess after 2 weeks; if reactions worsen or do not improve, consider alternative approaches 1, 4

For Abscess Formation

• Drainage is mandatory when an abscess is present 3
• Options range from instrumentation with a hypodermic needle to a wide incision with a scalpel 3
• For intolerable grade 2 or grade 3 paronychia, surgical treatment with partial nail plate avulsion may be necessary 1

Treatment for Chronic Paronychia

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 1, 5
• Silver nitrate chemical cauterization for excessive granulation tissue 1, 2
• Topical calcineurin inhibitors may be beneficial in steroid-resistant cases 3, 5
• For pyogenic granuloma formation, consider scoop shave removal with hyfrecation or silver nitrate application 2
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 1
• More aggressive surgical techniques may be required for recalcitrant cases, including eponychial marsupialization 6, 5

Prevention Strategies

• Keep hands and feet as dry as possible 1, 2
• Avoid repeated friction, trauma, and excessive pressure to nails 1, 2
• Regular application of emollients to cuticles and periungual tissues 1, 2
• Wear protective gloves during activities involving water or chemicals 1, 2
• Trim nails carefully, ensuring they are straight and not too short 1, 2
• Wear comfortable well-fitting shoes and cotton socks 1, 2

Common Pitfalls and Caveats

• Systemic antibiotics are often unnecessarily prescribed; they are only needed if adequate drainage cannot be achieved or if the patient is immunocompromised 3, 7
• Failure to identify and address the underlying cause (especially in chronic paronychia) leads to recurrence 5
• Chronic paronychia is often misdiagnosed as a fungal infection, leading to inappropriate antifungal treatment when the primary issue is irritant dermatitis 7, 5
• Patient education is paramount to reduce recurrence of both acute and chronic paronychia 3
• For paronychia associated with EGFR-TKIs (cancer treatments), specific management protocols should be followed as these cases may be more resistant to standard therapies 1