What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should follow a stepwise approach based on severity, with initial management including warm water or vinegar soaks, topical antiseptics like povidone-iodine 2%, and topical steroids, progressing to oral antibiotics and surgical intervention for more severe cases. 1, 2

Classification and Assessment

• Evaluate severity based on parameters including redness, edema, discharge, and presence of granulation tissue 1
• Check for presence of pus or abscess formation which would require drainage 2
• Assess for predisposing factors such as ingrown toenail (onychocryptosis) 1
• Determine if acute (sudden onset, often bacterial) or chronic (lasting >6 weeks, often irritant dermatitis) 3

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

• Implement warm water soaks for 15 minutes 3-4 times daily or white vinegar soaks (1:1 white vinegar:water) for 15 minutes daily 2
• Apply topical 2% povidone-iodine twice daily to the affected area 4, 2
• Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Regular application of emollients to cuticles and periungual tissues 4

Grade 2 (Moderate) Paronychia

• Consider dose reduction or interruption if paronychia is related to EGFR-TKI therapy 4
• Start oral antibiotics if signs of infection are present 2
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 4
• Apply silver nitrate weekly if over-granulation has developed 4, 2

Grade 3 (Severe) Paronychia

• Swab any pus for culture and prescribe appropriate antibiotics 4, 2
• Consider surgical intervention for drainage or partial nail avulsion 4, 2
• Discontinue EGFR-TKI therapy if applicable and only reinstate when AE has resolved to Grade 2 4
• Refer for specialist support (dermatology or podiatry) 4, 2

Special Considerations

For Chronic Paronychia

• Apply high-potency topical corticosteroids which have been found more effective than antifungals in chronic cases 5
• Consider intralesional triamcinolone acetonide for recalcitrant cases 2
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 4
• Recognize that chronic paronychia is often a form of contact dermatitis rather than infection 6

For Pyogenic Granuloma

• Silver nitrate chemical cauterization for excessive granulation tissue 4, 1
• Scoop shave removal with hyfrecation may be necessary 1
• Cryotherapy could also be considered in the treatment of pyogenic granuloma 4

Prevention of Recurrence

• Keep hands and feet as dry as possible; avoid prolonged soaking in water 4, 2
• Avoid nail trauma/injury and cutting nails too short 4, 2
• Trim nails straight across and not too short 4
• Moisturize hands and feet regularly with emollients applied to cuticles and periungual tissues 4, 2
• Wear protective gloves during wet work or exposure to irritants 4, 2
• Wear comfortable well-fitting shoes that protect nails without being restrictive 4

Common Pitfalls to Avoid

• Don't overlook potential secondary bacterial or mycological superinfections, which are present in up to 25% of cases 2, 7
• Don't rely solely on antifungals for chronic paronychia, as topical steroids have been found more effective 5
• Don't forget to obtain cultures before starting antibiotics in severe or recalcitrant cases 7
• Don't overlook systemic conditions or medications that may contribute to paronychia 8

Treatment Failure Management

• If initial treatment fails, obtain bacterial, viral, and fungal cultures 7
• Consider switching to a different antibiotic class based on culture results 7
• For paronychia not responding to cephalexin, consider sulfamethoxazole-trimethoprim for broader coverage including MRSA 7
• Reassess after 2 weeks of new treatment regimen 2, 7