What is the treatment for paronychia?

Treatment of Paronychia

The treatment of paronychia should follow a graded approach based on severity, with warm soaks, topical antiseptics, antibiotics, and surgical drainage for more severe cases.

Classification and Assessment

• Paronychia is an inflammation of the folds of tissue surrounding the nail of a toe or finger, and may be classified as either acute or chronic 1
• Evaluate severity based on parameters including redness, edema, discharge, and granulation tissue 2
• Check for presence of pus or abscess formation which would require drainage 2
• Assess for predisposing factors such as ingrown toenail (onychocryptosis) 2

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 3, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 3
• Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 2
• Reassess after 2 weeks; if reactions worsen or do not improve, proceed to next step 3

Grade 2 (Moderate) Paronychia

• Continue treatment with topical agents as above 3
• Obtain bacterial/viral/fungal cultures if infection is suspected 3
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 3
• Start oral antibiotics if signs of infection are present 3
• Reassess after 2 weeks; if reactions worsen or do not improve, proceed to next step 3

Grade 3 (Severe) Paronychia

• Interrupt any causative medications until condition improves to Grade 0/1 3
• Obtain bacterial/viral/fungal cultures if infection is suspected 3
• Continue topical treatments as above 3
• Consider partial nail avulsion for severe cases 3
• Swab any pus for culture and prescribe appropriate antibiotics 3
• Consider surgical intervention for drainage 3

Special Considerations

Acute Paronychia

• Main factor associated with development is direct or indirect trauma to the cuticle or nail fold 1
• Treatment options include warm compresses, topical antibiotics with or without corticosteroids, oral antibiotics, or surgical incision and drainage for more severe cases 1
• Secondary bacterial or mycological superinfections are present in up to 25% of cases 3

Chronic Paronychia

• Represents a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens 1
• Apply high-potency topical corticosteroids which have been found more effective than antifungals in chronic cases 2, 4
• Consider intralesional triamcinolone acetonide for recalcitrant cases 2
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 3
• For recalcitrant chronic paronychia, en bloc excision of the proximal nail fold or eponychial marsupialization may be options 1

Prevention of Recurrence

• Keep hands and feet as dry as possible; avoid prolonged soaking in water 2, 4
• Avoid nail trauma/injury and cutting nails too short 3, 2
• Moisturize hands and feet regularly with emollients applied to cuticles and periungual tissues 3
• Wear protective gloves during wet work or exposure to irritants 3
• Wear comfortable well-fitting shoes that protect nails without being restrictive 3
• Regular trimming of the nails ensuring that they are straight and not too short 3

Common Pitfalls to Avoid

• Don't overlook potential secondary bacterial or mycological superinfections, which are present in up to 25% of cases 3
• Don't delay surgical drainage when abscess is present, as this can lead to worsening infection 4
• Don't forget to address underlying causes in chronic paronychia, such as occupational exposures or systemic conditions 4, 5
• Don't rely solely on oral antibiotics without adequate drainage when an abscess is present 4
• Don't neglect patient education on preventive measures, which is paramount to reduce recurrence 4