What is the treatment for paronychia?

Treatment of Paronychia

For paronychia, begin with conservative management using topical 2% povidone-iodine twice daily combined with high-potency topical corticosteroids, and escalate to oral antibiotics or surgical drainage based on severity grading. 1, 2

Initial Assessment and Severity Grading

Evaluate the severity by examining for redness, edema, discharge, and granulation tissue formation. 1, 2 Check specifically for pus or abscess formation, which mandates drainage rather than conservative therapy alone. 1, 3 Assess whether an ingrown toenail (onychocryptosis) is present, as this requires specific management beyond standard paronychia treatment. 1

Grade 1 (Mild) Paronychia

Conservative management is appropriate for mild cases without abscess formation:

• Apply topical 2% povidone-iodine twice daily to the affected area. 4, 1, 2
• Use mid to high-potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation. 1, 2
• Implement warm water soaks for 15 minutes 3-4 times daily, or alternatively use white vinegar soaks (1:1 white vinegar:water dilution) for 15 minutes daily. 4, 2
• Apply emollients regularly to cuticles and periungual tissues. 4, 1

Important caveat: Grade 1 paronychia can escalate to Grade 2 very quickly, so patients must alert their healthcare provider at the first signs of worsening. 4

Grade 2 (Moderate) Paronychia

For moderate paronychia with signs of infection but no large abscess:

• Start oral antibiotics targeting likely pathogens (Staphylococcus aureus and Streptococcus species). 2, 3
• If initial treatment with cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA. 5
• Apply topical very potent steroids combined with topical antibiotics and/or antiseptics, preferably as combination preparations. 4, 2
• Apply silver nitrate weekly (by healthcare professional only) if over-granulation tissue has developed. 4, 2
• Consider dose reduction or interruption if paronychia is drug-induced (e.g., EGFR inhibitors). 4
• Refer to dermatology if no improvement is seen. 4

Grade 3 (Severe) Paronychia

Severe paronychia requires aggressive intervention:

• Swab any purulent discharge for bacterial, viral, and fungal cultures to identify resistant organisms. 5
• Prescribe appropriate antibiotics based on culture results and local resistance patterns. 2, 5, 3
• Surgical drainage is mandatory when an abscess is present. 1, 3, 6 Options range from instrumentation with a hypodermic needle to wide incision with a scalpel. 3
• For paronychia associated with ingrown toenail, consider techniques such as the dental floss nail technique to separate the lateral nail edge from underlying tissue. 1
• In recalcitrant cases, partial nail plate avulsion or en bloc excision of the proximal nail fold may be necessary. 2, 5
• Discontinue any causative medications (e.g., EGFR inhibitors) and only reinstate when resolved to Grade 2. 4

Chronic Paronychia (≥6 Weeks Duration)

Chronic paronychia represents an irritant dermatitis rather than primarily an infectious process:

• High-potency topical corticosteroids are more effective than antifungals for chronic cases. 4, 2, 7
• Apply topical corticosteroids alone or combined with topical antibiotics. 4
• For recalcitrant cases, consider intralesional triamcinolone acetonide. 1, 2
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases. 4, 2
• Address predisposing factors such as frequent water exposure or chemical irritants. 5, 3
• Be aware that secondary bacterial or mycological superinfections occur in up to 25% of cases. 1, 5

Special Considerations for Pyogenic Granuloma

If pyogenic granuloma develops (often with EGFR inhibitor therapy), use scoop shave removal with hyfrecation or silver nitrate application. 1 Cryotherapy is another option for treating pyogenic granuloma. 4

Prevention of Recurrence

Preventive measures are paramount to avoid recurrence:

• Trim nails straight across and not too short; avoid cutting nails too short or biting nails. 4, 1, 2
• Keep hands and feet as dry as possible; avoid prolonged soaking in soapy water without adequate protection. 4, 2
• Wear protective gloves (cotton gloves underneath washing gloves) during wet work or exposure to irritants. 4, 5
• Wear comfortable, well-fitting shoes that protect nails without being restrictive, along with cotton socks. 4, 1, 2
• Avoid repeated friction, trauma, and excessive pressure to the nail area. 4, 1
• Apply emollients daily to cuticles and periungual tissues. 4, 1, 2

Follow-Up and Monitoring

Reassess after 2 weeks of treatment. 2, 5 If no improvement is seen, refer to dermatology or podiatry for further evaluation and consideration of more aggressive interventions. 2, 5 For patients on EGFR inhibitors or other causative medications, close monitoring for early symptoms is essential. 4

Common Pitfalls to Avoid

Do not overlook secondary bacterial or mycological superinfections, which are present in up to 25% of paronychia cases. 1, 2 Obtain cultures when treatment fails or in severe cases. 5 Do not prescribe oral antibiotics alone without adequate drainage when an abscess is present. 3 For chronic paronychia, avoid focusing solely on antimicrobial therapy when the underlying issue is irritant dermatitis requiring topical corticosteroids. 7, 3