What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should be tailored based on whether it is acute or chronic, with first-line therapy consisting of warm soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine applied twice daily for 10-15 minutes. 1, 2

Classification and Initial Assessment

• Evaluate severity based on 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
• Determine if acute (less than 6 weeks) or chronic (6 weeks or longer) as treatment approaches differ 3

Treatment Algorithm for Acute Paronychia

Conservative Management (First-Line)

• 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 2
• Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 2
• For edema and pain, apply warm soaks with or without Burow solution or 1% acetic acid 3

When Abscess is Present

• Drainage is mandatory when abscess is present 3
• Options for drainage range from using a hypodermic needle to a wide incision with a scalpel 3
• After drainage, continue warm soaks and topical antibiotics 1

Antimicrobial Therapy

• Oral antibiotics are usually not needed if adequate drainage is achieved unless the patient is immunocompromised or has a severe infection 3
• For moderate to severe infection, select antibiotics based on likely pathogens 1
• Be aware that secondary bacterial or mycological superinfections are present in up to 25% of cases 2, 1

For Ingrown Toenail with Paronychia

• Use techniques such as dental floss nail technique to separate the lateral nail edge from underlying tissue 2
• Consider splinting with a flexible tube or acrylic treatment with gutter splint for onychocryptosis 2

Treatment Algorithm for Chronic Paronychia

First-Line Therapy

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 2
• Regular application of emollients to cuticles and periungual tissues 2
• Identify and eliminate exposure to irritants (acids, alkalis, and other chemicals) 3, 4

For Refractory Cases

• For recurrent, severe, or treatment-refractory cases, consider intralesional triamcinolone acetonide 2
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 2
• Consider topical calcineurin inhibitors as an alternative to steroids 3

Surgical Options for Chronic Paronychia

• Surgical treatment may be necessary for recalcitrant cases 4
• Options include en bloc excision of the proximal nail fold or eponychial marsupialization 4
• The Swiss roll technique may be effective for severe chronic paronychia 5

Management of Complications

Pyogenic Granuloma

• For granulation tissue formation, use silver nitrate chemical cauterization 2
• Consider scoop shave removal with hyfrecation for excessive granulation tissue 2
• Cryotherapy could also be considered in the treatment of pyogenic granuloma 2

Prevention of Recurrence

• Gentle nail care, including trimming nails straight across and not too short 2
• Avoid repeated friction, trauma, and excessive pressure 2
• Wear comfortable well-fitting shoes and cotton socks 2
• Use protective gloves during activities involving water or chemicals 1
• Patient education is paramount to reduce recurrence 3

Follow-up Recommendations

• Reassess after 2 weeks of treatment 1
• If no improvement is seen, consider referral to dermatology or podiatry 1
• For chronic paronychia, be aware that treatment may take weeks to months 3
• Investigate for unusual causes such as malignancy in cases unresponsive to standard treatment 6