What are the best treatments for paronychia (infection of the nail)

From the Guidelines

The most effective treatment for paronychia involves a combination of preventive measures and therapeutic management, including gentle skin care, avoidance of trauma, and the use of antimicrobial soaks, with topical treatments such as high-potency corticosteroids, topical antibiotics, and topical povidone iodine 2% b.i.d. being beneficial for grade 1 and 2 paronychia. When considering treatment options, it's essential to prioritize measures that reduce morbidity, mortality, and improve quality of life. According to the most recent and highest quality study available 1, preventive management of paronychia should include patient education on gentle skin care instructions, preventive correction of nail curvature, avoidance of repeated friction and trauma, and the use of antimicrobial soaks. Some key points to consider in the management of paronychia include:

• Gentle skin care instructions given to the patient
• Preventive correction of nail curvature with referral to a podiatrist if needed
• Avoidance of repeated friction and trauma/excessive pressure
• Wearing gloves while cleaning
• Avoiding biting nails or cutting nails too short
• The use of antimicrobial soaks and washing with cleansers and water
• Regular trimming of the nails ensuring that they are straight and not too short
• Daily application of topical emollients to cuticles and periungual tissues
• Wearing comfortable well-fitting shoes and cotton socks For therapeutic management, topical povidone iodine 2% b.i.d. has shown benefit in a controlled study for grade 1 and 2 paronychia 1. Additionally, oral antibiotics have shown benefit anecdotally, and topical timolol (0.5% gel, b.i.d. under occlusion for 1 month) has been reported to achieve complete clearance of toenail and fingernail paronychia and/or periungual pyogenic granulomas in some patients 1. In cases of intolerable grade 2 or grade 3 paronychia/pyogenic granuloma, surgical treatment with partial nail plate avulsion may be necessary 1.

From the Research

Treatment Options for Paronychia

• For acute paronychia, treatment options include:
  • Warm compresses 2, 3
  • Topical antibiotics, with or without corticosteroids 2, 3
  • Oral antibiotics, usually not needed unless the patient is immunocompromised or a severe infection is present 3
  • Surgical incision and drainage for more severe cases 2, 3
• For chronic paronychia, treatment options include:
  • Avoiding exposure to contact irritants 2, 3, 4
  • Topical steroid creams, which are more effective than systemic antifungals 2, 4
  • Application of emollient lotions 2
  • Topical antifungal agents, in combination with a corticosteroid 2
  • Surgical treatment, such as en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal 2, 4
  • Newer therapies, such as a combination of topical medications, including an insulating polymer, antifungals, and a molecule with anti-inflammatory activity 5

Specific Treatment Approaches

• For cases with Candida spp or bacterial infections, additional treatments may be necessary, such as oral fluconazole or clarithromycin 5
• For occupational hand disease, prolonged treatment and continuous prevention may be needed, and a combination of topical cream may be considered as a new alternative for treatment and prevention of paronychia 5

General Principles

• Patient education is paramount to reduce the recurrence of acute and chronic paronychia 3
• General preventive measures form the cornerstone of therapy for chronic paronychia 4