What is the treatment for paronychia?

Treatment of Paronychia

For paronychia, begin with conservative management using antiseptic soaks (dilute vinegar or povidone-iodine) twice daily combined with topical 2% povidone-iodine and high-potency topical corticosteroids, escalating to oral antibiotics for moderate infections and surgical drainage for severe cases with abscess formation. 1, 2

Initial Assessment

• Classify severity based on redness, edema, discharge, and presence of granulation tissue 1, 2
• Check for abscess formation which mandates drainage 1, 3
• Identify predisposing factors such as ingrown toenail (onychocryptosis), frequent water exposure, or chemical irritants 1, 4
• Distinguish acute versus chronic paronychia: acute presents with sudden onset inflammation, while chronic persists for ≥6 weeks and represents an irritant dermatitis 3, 5

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

• Implement antiseptic soaks: dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 6, 1, 2
• Use mid to high-potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Alternative soaking method: warm water soaks for 15 minutes 3-4 times daily 6, 2
• Continue current medications without dose reduction 6

Grade 2 (Moderate) Paronychia

• Start oral antibiotics if signs of infection are present 2, 4
• Apply topical combination therapy: very potent steroids combined with topical antibiotics and/or antiseptics 6, 2
• Consider dose reduction or interruption of causative medications (if drug-induced) until resolved 6
• Apply silver nitrate weekly by healthcare professional only if over-granulation tissue has developed 6
• Refer to dermatologist if no improvement after initial treatment 6
• Consult podiatrist for feet-related symptoms 6

Grade 3 (Severe) Paronychia

• Swab any pus for culture and prescribe appropriate antibiotics based on results 6, 2, 4
• Perform surgical drainage if abscess is present 1, 2, 3
• Consider partial nail plate removal for intolerable symptoms or pyogenic granuloma 6
• Discontinue causative medications (if drug-induced) and only reinstate when resolved to Grade 2 6
• Refer for specialist support (dermatology or hand surgery) 6, 4

Antibiotic Selection

• First-line oral antibiotic: cephalexin targeting likely gram-positive pathogens 4
• If cephalexin fails: switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 4
• Obtain cultures if treatment failure occurs, as secondary bacterial or mycological superinfections are present in up to 25% of cases 1, 4
• Topical antibiotics: mupirocin applied three times daily or fusidic acid applied 3-4 times daily 7, 8

Common pitfall: Oral antibiotics are often overused; they are usually not needed if adequate drainage is achieved unless the patient is immunocompromised or severe infection is present 3

Chronic Paronychia Management

• High-potency topical corticosteroids are more effective than antifungals for chronic cases 6, 2, 9
• Identify and eliminate irritants: acids, alkalis, chemicals, or excessive moisture exposure 3, 5
• Consider topical calcineurin inhibitors as alternative to steroids 3
• 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 6, 2

Important caveat: Treatment may take weeks to months for chronic paronychia 3

Special Situations

Pyogenic Granuloma Formation

• Scoop shave removal with hyfrecation or silver nitrate application 1
• Cryotherapy can also be considered 6

Ingrown Toenail with Paronychia

• Dental floss nail technique to separate lateral nail edge from underlying tissue 1
• Treat the causal toenail as primary management 5

Preventive Measures

• Nail care: trim nails straight across, not too short; avoid biting or cutting nails excessively 6, 4
• Moisture control: keep hands and feet dry; avoid prolonged soaking in soapy water 6, 4
• Protective measures: wear cotton gloves underneath washing gloves; use protective gloves during wet work 6, 4
• Footwear: wear comfortable well-fitting shoes and cotton socks that protect nails without being restrictive 6, 2
• Daily emollient application to cuticles and periungual tissues 6, 1, 2
• Avoid trauma: prevent repeated friction, excessive pressure, and nail injury 6, 4

Follow-up Protocol

• Reassess after 2 weeks of treatment 2, 4
• If no improvement: consider referral to dermatology or podiatry for further evaluation 1, 2, 4
• Monitor for pyogenic granuloma development in patients on EGFR inhibitors 6

Critical pitfall: Grade 1 paronychia can escalate to Grade 2 very quickly, so patients must alert healthcare professionals at first signs of worsening 6