What is the treatment for paronychia?

Treatment of Paronychia

For mild paronychia, start with warm water or white vinegar soaks 3-4 times daily combined with topical 2% povidone-iodine twice daily and high-potency topical corticosteroids; escalate to oral antibiotics for moderate cases, and consider surgical drainage for severe cases with abscess formation. 1, 2

Initial Assessment

Evaluate the severity by examining for:

• Degree of erythema, edema, and tenderness 1, 2
• Presence of purulent discharge or abscess formation requiring drainage 1, 2
• Associated ingrown toenail (onychocryptosis) that may need specific intervention 1, 2
• Duration of symptoms to distinguish acute (less than 6 weeks) from chronic paronychia 3

Treatment Algorithm by Severity Grade

Grade 1 (Mild) Paronychia

Conservative measures are first-line:

• Implement warm water soaks for 15 minutes 3-4 times daily, or alternatively use white vinegar soaks (1:1 white vinegar:water ratio) for 15 minutes daily 4, 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 4, 1, 2
• Use 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 4

Grade 2 (Moderate) Paronychia

Intensify topical therapy and add systemic antibiotics:

• Apply very potent topical corticosteroids combined with topical antibiotics and/or antiseptics (combination preparations preferred) 4, 1
• Start oral antibiotics targeting likely pathogens (Staphylococcus aureus and Streptococcus species) 1, 3
• If initial antibiotic (e.g., cephalexin) fails, switch to sulfamethoxazole-trimethoprim for broader coverage including MRSA 5
• Apply silver nitrate weekly (by healthcare professional only) if over-granulation tissue has developed 4, 2
• Consider referral to dermatology or podiatry if no improvement within 2 weeks 4, 1

Grade 3 (Severe) Paronychia

Surgical intervention is often necessary:

• Swab any purulent material for bacterial, viral, and fungal cultures to identify resistant organisms 5
• Prescribe appropriate antibiotics based on culture results and local resistance patterns 1, 3
• Perform surgical drainage for abscess formation or consider partial nail plate avulsion for intolerable symptoms 4, 1, 2
• Continue topical very potent corticosteroids, antibiotics, and antiseptics 4, 1

Special Considerations for Chronic Paronychia

Chronic paronychia (symptoms ≥6 weeks) requires a different approach:

• High-potency topical corticosteroids are more effective than antifungals and should be first-line therapy 1, 6
• Recognize that chronic paronychia is primarily an irritant contact dermatitis, not an infection 3, 6
• Address predisposing factors including frequent water exposure, chemical irritants, and occupational hazards 3, 6
• 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

Prevention of Recurrence

Patient education is paramount to prevent recurrence:

• Keep hands and feet as dry as possible; avoid prolonged soaking in soapy water 4, 2
• Trim nails straight across and not too short to avoid trauma 4, 2
• Apply emollients daily to cuticles and periungual tissues 4, 1, 2
• Wear protective cotton gloves underneath washing gloves during wet work 4, 2
• Wear comfortable, well-fitting shoes that protect nails without being restrictive 4, 2
• Avoid nail biting, cuticle manipulation, and excessive pressure 4

Common Pitfalls to Avoid

• Do not overlook secondary infections: Up to 25% of paronychia cases have bacterial or fungal superinfections that require specific antimicrobial therapy 1, 5
• Do not delay drainage: Presence of an abscess mandates surgical drainage; antibiotics alone are insufficient 3, 7
• Do not treat chronic paronychia as acute infection: Chronic cases are inflammatory, not infectious, and require corticosteroids rather than prolonged antibiotics 3, 6
• Do not ignore treatment failure: If no improvement after 2 weeks, obtain cultures and consider referral rather than continuing the same regimen 1, 2, 5

Follow-Up Protocol

• Reassess all patients after 2 weeks of treatment 1, 2, 5
• Refer to dermatology or podiatry if no improvement is observed 4, 1, 2
• For chronic cases, treatment may require weeks to months with ongoing preventive measures 3, 6