What is the 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, escalating to oral antibiotics and surgical drainage only if conservative measures fail after 1-2 weeks. 1, 2

Initial Assessment

Evaluate the severity using four key parameters to guide treatment intensity: 3, 1

• Redness - assess degree of erythema around nail fold
• Edema - evaluate swelling and tenderness of lateral nail folds
• Discharge - check for pus or abscess formation requiring drainage
• Granulation tissue - look for friable tissue mimicking ingrown nails

Recognize that secondary bacterial or fungal superinfections occur in up to 25% of cases, involving both gram-positive and gram-negative organisms. 3, 1

Treatment Algorithm by Severity Grade

Grade 1 (Mild) Paronychia

Conservative management is sufficient and should not be escalated prematurely: 1, 2

• Antiseptic soaks: Warm water for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 vinegar:water ratio) for 15 minutes daily 3, 1
• Topical povidone-iodine 2% applied twice daily - this has demonstrated benefit in controlled studies 3, 1, 2
• Mid to high-potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Continue current activities but monitor closely as Grade 1 can escalate to Grade 2 rapidly 3

Grade 2 (Moderate) Paronychia

Escalate treatment intensity while considering whether to continue aggravating activities: 3, 1

• Topical therapy: Very potent topical steroids combined with antibiotics and/or antiseptics (preferably combination preparations) 3, 1
• Oral antibiotics if signs of infection are present - these have shown anecdotal benefit 3, 1
• Silver nitrate chemical cauterization applied weekly by healthcare professional only if over-granulation tissue has developed 3, 2
• Potassium permanganate prophylactic soaks as an antiseptic option 3, 2
• Referral to podiatrist for feet-related symptoms 3
• Consider dose reduction or interruption if paronychia is medication-related (e.g., EGFR inhibitors) 3

Grade 3 (Severe) Paronychia

Aggressive intervention is mandatory to prevent permanent nail damage: 3, 1

• Swab any pus for culture and prescribe appropriate antibiotics based on sensitivities 3, 1
• Surgical drainage or partial nail avulsion for intolerable symptoms or pyogenic granuloma 3, 1
• Discontinue causative medications (if applicable) and only reinstate when resolved to Grade 2 3
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics as combination preparations 3, 1
• Specialist referral to dermatology or hand surgery for further management 3, 1

Chronic Paronychia (≥6 Weeks Duration)

High-potency topical corticosteroids are more effective than antifungals for chronic cases, contrary to older practice patterns: 1, 4

• High-potency topical corticosteroids alone or combined with topical antibiotics 3, 2
• Intralesional triamcinolone acetonide for recalcitrant cases 1, 2
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases 3, 1, 5
• Address underlying irritant exposure - chronic paronychia represents an irritant dermatitis from repeated barrier breach 6, 7, 4

Prevention Strategies (Critical for All Patients)

Patient education on prevention is paramount and should be systematically promoted from treatment initiation: 3

• Keep hands and feet dry - avoid prolonged soaking in soapy water without protection 3, 1, 2
• Avoid nail trauma - do not bite nails or cut them too short 3, 1
• Trim nails straight across ensuring they are not too short 3, 2
• Daily application of emollients to cuticles and periungual tissues 3, 1, 2
• Wear protective gloves during wet work or chemical exposure - cotton gloves underneath washing gloves 3, 2, 5
• Wear comfortable, well-fitting shoes and cotton socks that protect nails without restriction 3, 2

Follow-Up and Reassessment

Reassess after 2 weeks of treatment - if no improvement or worsening occurs, escalate therapy or refer to specialist. 3, 1, 2

Common Pitfalls to Avoid

• Do not overlook secondary infections - bacterial or fungal superinfections are present in 25% of cases and require targeted antimicrobial therapy 3, 1
• Do not delay surgical intervention for Grade 3 paronychia with abscess formation - inadequate drainage leads to chronic inflammation 1, 7
• Do not prescribe antifungals as first-line for chronic paronychia - topical corticosteroids are more effective 1, 4
• Do not apply silver nitrate without over-granulation tissue present - it should only be used for excessive granulation 3, 2
• Do not continue causative medications at full dose for Grade 3 paronychia - dose interruption or discontinuation may be necessary 3