What antibiotics are recommended for the treatment of paronychia?

Antibiotic Treatment for Paronychia

For paronychia treatment, topical antibiotics combined with povidone iodine 2% are first-line therapy, with oral antibiotics reserved for cases with suspected infection, discharge, or treatment failure. 1

Treatment Algorithm Based on Severity

Mild Paronychia (Grade 1)

• Apply topical povidone iodine 2% twice daily to the affected area 2
• Combine with topical antibiotics and corticosteroids to reduce inflammation 2, 1
• Implement antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 3, 4
• Monitor for 2 weeks; if no improvement, proceed to next step 2

Moderate Paronychia (Grade 2)

• Continue topical povidone iodine 2% and topical antibiotics/corticosteroids 2
• Obtain bacterial/viral/fungal cultures if infection is suspected 2
• Add oral antibiotics if discharge is present or infection is suspected 2, 5
• Recommended oral antibiotics include:
  • Cephalexin as first-line therapy 6
  • If cephalexin fails, consider sulfamethoxazole-trimethoprim for broader coverage including MRSA 6
  • Oral cephalosporines, ciprofloxacin, levofloxacin, or moxifloxacin are effective against the majority of isolated microorganisms 5
• Reassess after 2 weeks; if worsening or no improvement, proceed to next step 2

Severe Paronychia (Grade 3 or intolerable Grade 2)

• Interrupt causative factors 2
• Obtain bacterial/viral/fungal cultures 2
• Continue topical treatments as above 2
• Administer oral antibiotics based on culture results or empirically if severe infection is present 2, 5
• Consider partial nail avulsion for severe cases not responding to medical therapy 2, 3
• Surgical drainage is indicated if abscess is present 4, 7

Antimicrobial Selection Considerations

Bacterial Pathogens

• Both gram-positive and gram-negative organisms have been implicated in paronychia 2, 5
• In a microbiological analysis of paronychia cases, 72% were Gram-positive bacteria, 23% Gram-negative bacteria, and 5% Candida species 5
• Secondary bacterial or mycological superinfections are present in up to 25% of paronychia cases 2, 3

Fungal Considerations

• For Candida-associated paronychia, topical imidazole lotions are first-line treatment 1
• In severe cases with proven candidiasis, oral fluconazole may be added to topical therapy 8
• Consider fungal etiology in chronic cases not responding to antibacterial therapy 9

Prevention of Recurrence

• Keep hands dry and avoid trauma to nails 1, 3
• Wear protective gloves during activities involving water or chemicals 3
• Trim nails straight across and not too short 2, 3
• Apply emollients to cuticles and periungual tissues daily 2
• For chronic paronychia, identify and eliminate irritant exposures 8

Common Pitfalls to Avoid

• Do not use systemic antibiotics unless infection is proven or strongly suspected 9
• Avoid prolonged use of topical steroids without addressing underlying cause 1
• Don't overlook potential secondary fungal infections, especially in chronic cases 1, 8
• Remember that paronychia can be a side effect of anticancer therapies, requiring specific management approaches 2