What is the best antibiotic ointment for paronychia?

Best Antibiotic Ointment for Paronychia

For paronychia, combination topical therapy with antibiotics and corticosteroids is recommended, with topical povidone iodine 2% being the most evidence-based first-line antiseptic agent. 1

Treatment Approach by Severity

Grade 1 Paronychia (Mild: Nail fold edema or erythema)

• Apply topical povidone iodine 2% twice daily as the primary antiseptic agent 1
• Combine with topical antibiotics and mid-to-high potency topical corticosteroid ointment applied to nail folds twice daily 1
• Continue current medications and reassess after 2 weeks 1

The ESMO guidelines specifically recommend this combination approach based on controlled studies showing benefit with topical povidone iodine 2% for grade 1 and 2 paronychia. 1 The addition of corticosteroids addresses the inflammatory component, which is particularly important since paronychia often represents an inflammatory reaction rather than pure infection. 1

Grade 2 Paronychia (Moderate: Pain, discharge, or nail plate separation)

• Continue topical povidone iodine 2% twice daily 1
• Add combination topical antibiotics with corticosteroids 1
• Consider oral antibiotics if infection is suspected (obtain bacterial/viral/fungal cultures first) 1
• Alternative: Topical timolol 0.5% gel twice daily under occlusion has shown complete clearance in controlled studies 1

Adjunctive Measures

• Daily dilute vinegar soaks (50:50 dilution) to nail folds for 10-15 minutes twice daily 1
• Apply antiseptic soaks to help sterilize the subcuticular space 1

Important Clinical Considerations

Secondary infection occurs in up to 25% of cases, involving both gram-positive and gram-negative organisms. 1 When infection is suspected:

• Obtain cultures before starting systemic antibiotics 1
• Empirical oral antibiotic coverage should target Staphylococcus aureus and Streptococcus species 2, 3
• For oral therapy when needed: cephalosporins, ciprofloxacin, levofloxacin, or moxifloxacin have high activity against isolated organisms 3

Avoid topical steroids if purulent drainage is present until infection is adequately treated. 1 The presence of pus mandates drainage, and topical steroids should be stopped to avoid worsening bacterial infection. 2

Special Populations

For chronic paronychia (symptoms ≥6 weeks), the pathophysiology differs—this represents irritant contact dermatitis rather than infection. 2, 4 Treatment focuses on:

• High-potency topical corticosteroids or calcineurin inhibitors 2
• Imidazole lotion alternating with antibacterial lotion until cuticle integrity is restored 1
• Addressing underlying irritant exposure 2, 5

For drug-induced paronychia (EGFR inhibitors, taxanes, MEK inhibitors), the same topical approach applies, but recognize this is primarily an inflammatory process from altered keratinocyte differentiation rather than primary infection. 1

Key Pitfalls to Avoid

• Do not use systemic antibiotics routinely unless infection is proven or adequate drainage cannot be achieved 4, 5
• Do not confuse acute bacterial paronychia with chronic inflammatory paronychia—the latter will not respond to antibiotics alone 2, 4
• Reassess after 2 weeks; if no improvement, escalate therapy or consider surgical intervention 1