What is the treatment for paronychia?

Treatment of Paronychia

The most effective treatment for paronychia includes warm water or dilute vinegar soaks, topical 2% povidone-iodine, and high-potency topical corticosteroids, with oral antibiotics and drainage procedures reserved for more severe cases. 1, 2

Classification and Initial Assessment

• Evaluate severity based on redness, edema, discharge, and presence of granulation tissue 1, 2
• Determine if the paronychia is acute (sudden onset) or chronic (lasting >6 weeks) 3
• Check for abscess formation which would require drainage 2
• Obtain bacterial, viral, and fungal cultures in cases of suspected infection, especially if treatment-resistant 1

First-Line Treatment

Conservative Management

• Implement warm water soaks for 15 minutes 3-4 times daily 1
• Alternatively, use white vinegar soaks (1:1 white vinegar:water) for 15 minutes daily 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 2
• Use high-potency topical corticosteroids alone or combined with topical antibiotics to reduce inflammation 1, 2
• Consider potassium permanganate soaks as an antiseptic option 1

Second-Line Treatment

Antimicrobial Therapy

• If no improvement after 1-2 weeks of conservative treatment, consider oral antibiotics 1
• For moderate to severe infections, select antibiotics based on likely pathogens 2
• If treatment with cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 4
• Be aware that secondary bacterial or fungal superinfections occur in up to 25% of cases 2, 4

Surgical Interventions

• Drain any abscess that has formed 3, 5
• For paronychia with ingrown toenail, use techniques such as dental floss to separate the lateral nail edge from underlying tissue 2
• For excessive granulation tissue, consider silver nitrate chemical cauterization applied weekly 1, 2
• In chronic, severe cases, surgical options include:
  • Swiss roll technique for severe cases 6
  • En bloc excision of the proximal nail fold or eponychial marsupialization 7

Additional Therapies

• Topical timolol (0.5% gel, twice daily under occlusion for 1 month) has shown benefit in some cases 1, 2
• For recurrent or treatment-refractory cases, consider intralesional triamcinolone acetonide 2

Prevention of Recurrence

• Keep hands and feet dry; avoid prolonged soaking in water 1, 4
• Avoid nail trauma/injury and cutting nails too short 1, 2
• Moisturize regularly with emollients applied to cuticles and periungual tissues 1, 2
• Wear protective gloves during wet work or exposure to irritants 1, 2, 4
• Ensure proper nail care: trim nails straight across 2, 4
• Wear comfortable, well-fitting shoes that protect toenails 2

Follow-up Recommendations

• Reassess after 1-2 weeks of treatment 1, 4
• If no improvement is seen, consider referral to dermatology, podiatry, or hand surgery 1, 2
• For chronic paronychia unresponsive to standard treatments, investigate for unusual causes such as malignancy 8

Special Considerations

• Blackening may indicate tissue necrosis requiring more careful monitoring 1
• If paronychia is associated with anticancer agents (especially EGFR inhibitors or taxanes), consult with the oncology team 1
• Chronic paronychia is often a form of contact dermatitis and may require dermatology consultation 8, 7