What is the treatment for paronychia?

Treatment of Paronychia

For acute paronychia, start with warm water or white vinegar soaks (1:1 dilution) 3-4 times daily for 15 minutes, combined with topical 2% povidone-iodine twice daily and mid-to-high potency topical steroid ointment to the nail folds twice daily. 1, 2, 3

Initial Assessment

Before initiating treatment, evaluate the following parameters:

• Severity grading based on redness, edema, discharge, and presence of granulation tissue 1, 2
• Presence of pus or abscess formation which mandates drainage rather than conservative management alone 1, 2
• Predisposing factors including ingrown toenail (onychocryptosis), occupational exposures, or medication-induced causes (such as EGFR tyrosine kinase inhibitors) 1, 2
• Duration of symptoms to distinguish acute (less than 6 weeks) from chronic paronychia (6 weeks or longer) 4

Treatment Algorithm by Severity Grade

Grade 1 (Mild) Paronychia

• Implement antiseptic soaks: warm water for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 white vinegar:water ratio) for 15 minutes daily 1, 3
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 2, 3
• Use mid-to-high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2, 3
• Continue current medications without dose adjustment if drug-induced 5
• Monitor closely as Grade 1 can escalate to Grade 2 rapidly 5

Grade 2 (Moderate) Paronychia

• Start oral antibiotics if signs of infection are present 1, 3
  • First-line: Cephalexin or amoxicillin-clavulanate (Augmentin) 500/125 mg every 12 hours 3
  • If cephalexin fails: Sulfamethoxazole-trimethoprim (Bactrim) provides broader coverage including MRSA 2, 3
  • Avoid clindamycin due to inadequate streptococcal coverage and increasing resistance patterns 3
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 5, 1
• Consider dose reduction or interruption of causative medications (e.g., EGFR-TKIs) until resolved 5
• Apply silver nitrate weekly by healthcare professional only if over-granulation has developed 5, 1
• Refer to dermatologist if no improvement after initial treatment 5, 1
• Consult podiatrist for feet-related symptoms 5

Grade 3 (Severe) Paronychia

• Swab any pus for culture before starting antibiotics 1, 3
• Prescribe appropriate antibiotics based on culture results and local resistance patterns 3, 4
• Perform surgical drainage if abscess is present 1, 4
  • Options range from instrumentation with hypodermic needle (lifting nail fold with 21G or 23G needle) to wide incision with scalpel 4, 6
  • Oral antibiotics usually not needed if adequate drainage is achieved, unless patient is immunocompromised or severe infection is present 3, 4
• Consider partial nail avulsion for recalcitrant cases 1
• Discontinue causative medications (e.g., EGFR-TKIs) and only reinstate when resolved to Grade 2 5
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics 5, 1
• Refer for specialist support (dermatology or podiatry) 5, 1

Chronic Paronychia Management

For chronic paronychia (symptoms ≥6 weeks), high-potency topical corticosteroids are more effective than antifungals and should be first-line treatment. 1, 7

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 1, 2, 7
• Regular application of emollients to cuticles and periungual tissues 1, 2
• Identify and eliminate irritants (acids, alkalis, chemicals, excessive moisture) which are the primary cause 4, 7
• Consider intralesional triamcinolone acetonide for recalcitrant cases 1, 2
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 1, 2
• Surgical options for severe refractory cases include en bloc excision of proximal nail fold or eponychial marsupialization 7

Critical Considerations and Common Pitfalls

• Secondary bacterial or mycological superinfections are present in up to 25% of paronychia cases 1, 2, 3
  • Do not assume purely bacterial or purely fungal etiology without appropriate testing
  • Consider combination therapy when infection is suspected
• Obtain bacterial cultures before starting antibiotics, especially in severe cases or treatment failures 3
• Drug-induced paronychia (particularly from EGFR-TKIs) usually emerges 1-6 months after treatment initiation and requires specific dose modification protocols 5
• Avoid prolonged use of antifungals as monotherapy for chronic paronychia, as topical steroids are more effective 1, 7
• Do not overlook pyogenic granuloma formation, which requires scoop shave removal with hyfrecation or silver nitrate application 2

Prevention of Recurrence

• Keep hands and feet as dry as possible; avoid prolonged soaking in water without adequate protection 5, 1, 2
• Avoid nail trauma/injury and cutting nails too short; trim nails straight across 1, 2
• Moisturize hands and feet regularly with emollients applied to cuticles and periungual tissues 1, 2
• Wear protective gloves (cotton gloves underneath washing-up gloves) during wet work or exposure to irritants 5, 2
• Wear comfortable well-fitting shoes that protect nails without being restrictive, and cotton socks 5, 1, 2
• Dry feet carefully before putting on shoes 5

Follow-up Protocol

• Reassess after 2 weeks of treatment 1, 2, 3
• If no improvement is seen, refer to dermatology or podiatry for further evaluation 1, 2, 3
• Chronic paronychia treatment may take weeks to months to achieve full resolution 4, 7