Treatment for Paronychia
The treatment for paronychia should follow a stepwise approach based on severity, with first-line management including antiseptic soaks, topical antimicrobials, and anti-inflammatory agents, while surgical drainage is reserved for cases with abscess formation. 1
Classification and Initial Assessment
- Paronychia is classified as acute (sudden onset, often infectious) or chronic (lasting >6 weeks, typically irritant dermatitis) 2
- Evaluate severity based on parameters including redness, edema, discharge, and granulation tissue 1
- Check for presence of pus or abscess formation which would require drainage 1
- Assess for predisposing factors such as ingrown toenail (onychocryptosis) 1
Conservative Management (First-Line)
For Acute Paronychia:
- Implement antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1, 2
- Apply topical 2% povidone-iodine twice daily to the affected area 3, 1
- Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1
- Warm soaks with or without Burow solution or 1% acetic acid can help reduce inflammation 2
For Chronic Paronychia:
- Apply high-potency topical corticosteroids alone or combined with topical antibiotics 3, 4
- Regular application of emollients to cuticles and periungual tissues 3, 1
- Topical calcineurin inhibitors may be beneficial in steroid-resistant cases 4
Antimicrobial Therapy
- For moderate to severe infection, oral antibiotics should be selected based on likely pathogens 1, 5
- If initial treatment with cephalexin fails, consider switching to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 5
- Be aware that secondary bacterial or mycological superinfections are present in up to 25% of paronychia cases 3, 5
- Consider obtaining bacterial, viral, and fungal cultures in treatment-resistant cases 5
Surgical Interventions
- For paronychia with abscess formation, drainage is mandatory 2, 6
- Drainage options range from using a hypodermic needle to a wide incision with a scalpel 2
- For paronychia with onychocryptosis (ingrown toenail), use techniques such as dental floss nail technique to separate the lateral nail edge from underlying tissue 1
- Silver nitrate chemical cauterization for excessive granulation tissue 3, 1
- In severe chronic cases, surgical options include en bloc excision of the proximal nail fold or eponychial marsupialization 4, 7
Special Considerations
- For pyogenic granuloma formation, consider scoop shave removal with hyfrecation or silver nitrate application 1
- For recurrent, severe, or treatment-refractory cases, consider intralesional triamcinolone acetonide 1
- Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 3
- Patients with chronic paronychia unresponsive to standard treatment should be investigated for unusual causes, such as malignancy 6
Prevention of Recurrence
- Gentle nail care: trim nails straight across and not too short 3, 5
- Avoid repeated friction, trauma, and excessive pressure 3
- Wear comfortable well-fitting shoes and cotton socks 3
- Use protective gloves during activities involving water or chemicals 1, 5
- Patient education is paramount to reduce the recurrence of acute and chronic paronychia 2