What is the best treatment for paronychia?

Treatment of Paronychia

For acute paronychia, start with warm water or white vinegar soaks 3-4 times daily combined with topical 2% povidone-iodine twice daily, reserving antibiotics only for cases with significant infection or abscess formation that requires drainage. 1

Initial Assessment

Evaluate the severity by examining for:

• Redness, edema, discharge, and granulation tissue to grade the paronychia 2, 1
• Presence of pus or abscess formation, which mandates surgical drainage 1, 3
• Predisposing factors such as ingrown toenail, nail trauma, or occupational exposures 1, 4
• Duration of symptoms: acute (<6 weeks) versus chronic (≥6 weeks) 3

Note that secondary bacterial or fungal superinfections occur in up to 25% of cases, involving both gram-positive and gram-negative organisms 2, 5.

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 ratio) for 15 minutes daily 1, 3
• Apply topical 2% povidone-iodine twice daily, which has demonstrated benefit in controlled studies 2, 1, 6
• Use mid to high-potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 3
• Consider topical antibiotics (such as bacitracin applied 1-3 times daily) combined with steroids when simple soaks are insufficient 1, 7, 3

Grade 2 (Moderate) Paronychia

• Continue all Grade 1 measures 1
• Start oral antibiotics if signs of infection are present, though evidence for their benefit is primarily anecdotal 2, 1
• Apply combination topical preparations containing very potent steroids, antifungals, antibiotics, and/or antiseptics 1, 8
• If abscess is present, perform drainage using techniques ranging from needle instrumentation to scalpel incision 3, 4

Grade 3 (Severe) Paronychia

• Obtain culture of any purulent discharge to guide antibiotic selection 1, 5
• Perform surgical drainage or partial nail avulsion for intolerable symptoms or pyogenic granuloma 2, 1
• Consider silver nitrate chemical cauterization for granulation tissue 2, 6
• Prescribe appropriate antibiotics based on culture results; if MRSA is suspected or cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage 5

Chronic Paronychia (≥6 weeks duration)

Chronic paronychia represents an irritant contact dermatitis rather than primarily an infection 3, 4:

• Apply high-potency topical corticosteroids, which are more effective than antifungals in chronic cases 1, 3
• Consider topical calcineurin inhibitors as an alternative anti-inflammatory agent 3
• For recalcitrant cases, use intralesional triamcinolone acetonide 1
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases 2, 1, 6
• Identify and eliminate irritant exposures (acids, alkalis, chemicals, excessive moisture) common in housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 3
• Consider dermatology referral for suspected chronic cases or those unresponsive to standard treatment 1, 4

Prevention of Recurrence

Patient education is paramount to reduce recurrence 3:

• Keep hands and feet dry; avoid prolonged water exposure 1, 3
• Wear protective gloves during wet work or chemical exposure 2, 1, 6
• Trim nails straight across and not too short; avoid biting nails 2, 1, 6
• Apply emollients daily to cuticles and periungual tissues 2, 1, 6
• Wear comfortable, well-fitting shoes and cotton socks 2, 1, 6
• Avoid trauma and excessive pressure to the nail area 2, 1

Follow-up and Monitoring

• Reassess after 2 weeks of treatment 2, 1, 5
• If no improvement or worsening occurs, consider referral to dermatology, podiatry, or hand surgery 1, 5, 6
• For drug-induced paronychia (especially with EGFR inhibitors or taxanes), dose interruption or discontinuation may be necessary if reactions worsen 2

Critical Pitfalls to Avoid

• Don't overlook secondary infections: Up to 25% have bacterial or fungal superinfection requiring specific antimicrobial therapy 2, 5
• Don't prescribe oral antibiotics routinely: They are only needed for significant infection or when adequate drainage cannot be achieved, particularly in immunocompromised patients 3, 9
• Don't miss chronic paronychia masquerading as infection: This is an irritant dermatitis requiring steroids and irritant avoidance, not prolonged antibiotics 3, 4
• Don't ignore occupational factors: Chronic cases often require workplace modifications for successful treatment 3, 8
• Don't delay drainage of abscesses: Presence of pus mandates surgical intervention 1, 3, 4