Management of Paronychia
The recommended management for paronychia includes antiseptic soaks, topical treatments (steroids and antimicrobials), and in more severe cases, oral antibiotics or surgical intervention, with treatment approach determined by severity. 1, 2
Classification and Assessment
- Paronychia is an inflammatory condition of the nail folds that can be classified as acute or chronic (symptoms lasting ≥6 weeks) 3
- Severity should be evaluated based on parameters including redness, edema, discharge, and granulation tissue 2
- Secondary bacterial or mycological superinfections are present in up to 25% of cases 1, 2
- Assess for predisposing factors such as ingrown toenail (onychocryptosis), which may require specific management 2
Treatment Algorithm by Severity
Mild (Grade 1) Paronychia
- Implement antiseptic soaks with dilute vinegar (1:1 white vinegar:water) or warm water for 15 minutes 3-4 times daily 1, 2, 3
- Apply topical 2% povidone-iodine twice daily to the affected area 1, 2
- Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 2
- Regular application of emollients to cuticles and periungual tissues 1, 2
Moderate (Grade 2) Paronychia
- Continue conservative measures as above 1, 2
- Consider oral antibiotics if signs of infection are present 1, 3
- Apply silver nitrate weekly if over-granulation tissue has developed 1
- Consider dose reduction or interruption of EGFR-TKI if paronychia is medication-induced 1
- Consult podiatrist for feet-related symptoms 1
Severe (Grade 3) Paronychia or Abscess
- Surgical drainage is mandatory if abscess is present 3
- Options for drainage range from using a hypodermic needle to wide incision with a scalpel 3
- Consider partial nail avulsion for severe cases 1
- For medication-induced paronychia, discontinue the causative agent until resolved to Grade 2 1
- Swab any pus for culture and prescribe appropriate antibiotics 1
Special Considerations for Chronic Paronychia
- Chronic paronychia represents an irritant dermatitis to the breached nail barrier 3
- Treatment focuses on eliminating irritant exposure while treating inflammation 3, 4
- High-potency topical corticosteroids alone or combined with topical antibiotics are recommended 1, 2
- For recalcitrant cases, consider intralesional triamcinolone acetonide 2
- Topical calcineurin inhibitors may be beneficial in steroid-resistant cases 4
Management of Complications
- For pyogenic granuloma formation, consider scoop shave removal with hyfrecation or silver nitrate application 2
- Topical timolol 0.5% gel twice daily under occlusion has shown benefit for periungual pyogenic granulomas, especially in patients on EGFR inhibitors 1, 5, 2
- For ingrown toenails with paronychia, techniques such as dental floss nail technique to separate the lateral nail edge from underlying tissue may be helpful 2
Prevention of Recurrence
- Gentle nail care, trimming nails straight across and not too short 1, 2
- Avoid repeated friction, trauma, and excessive pressure 1, 2
- Wear comfortable well-fitting shoes and cotton socks 1, 2
- Use protective gloves during activities involving water or chemicals 1, 2
- Preventive correction of nail curvature with referral to a podiatrist if needed 1
Follow-up
- Reassess after 2 weeks of treatment 1, 2
- If reactions worsen or do not improve, consider referral to dermatology or podiatry 1, 2
- For medication-induced paronychia, dose interruption or discontinuation per protocol may be necessary if no improvement 1
Common Pitfalls to Avoid
- Avoid systemic antibiotics unless infection is proven or patient is immunocompromised 3, 6
- Do not neglect underlying causes such as contact irritants or medication side effects 3, 4
- Chronic paronychia unresponsive to standard treatment should be investigated for unusual causes, including malignancy 7
- Surgical drainage should not be delayed if abscess is present, as topical treatments alone will be insufficient 3