What is the treatment for a paronychia infection?

Treatment of Paronychia Infection

For acute paronychia, start with antiseptic soaks (warm water or dilute white vinegar 1:1 for 15 minutes 3-4 times daily) combined with topical 2% povidone-iodine twice daily and mid-to-high potency topical corticosteroid 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 granulation tissue presence 1, 2
• Presence of abscess or pus collection which mandates drainage rather than conservative management alone 1, 2
• Predisposing factors including ingrown toenail (onychocryptosis), occupational exposures (housekeepers, dishwashers, bartenders), or medication-induced causes 2, 4
• Duration of symptoms to distinguish acute (less than 6 weeks) from chronic paronychia (6 weeks or longer) 4, 5

Treatment Algorithm by Severity

Grade 1 (Mild): Nail fold edema or erythema with cuticle disruption

• Antiseptic soaks: Warm water for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 dilution with water) for 15 minutes daily 1, 3
• Topical 2% povidone-iodine applied twice daily to affected area 6, 1, 3
• Mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2, 3
• Reassess after 2 weeks; if no improvement or worsening, escalate to Grade 2 treatment 6, 2, 3

Grade 2 (Moderate): Nail fold edema/erythema with pain, discharge, or nail plate separation

• Continue all Grade 1 interventions 6, 2
• Add oral antibiotics if signs of infection are present:
  • First-line: Cephalexin OR amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) 2, 3
  • If cephalexin fails: Switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1, 3
  • Avoid clindamycin due to inadequate streptococcal coverage and increasing resistance patterns 3
• Obtain bacterial/viral/fungal cultures if infection is suspected, as up to 25% have secondary bacterial or mycological superinfections 6, 1, 3
• Reassess after 2 weeks; if no improvement, escalate to Grade 3 treatment 6, 2

Grade 3 (Severe): Surgical intervention indicated, limiting self-care activities

• Swab any pus for culture before starting antibiotics 2, 3
• Perform surgical drainage of abscess—this is mandatory when pus is present 1, 2, 4
  • Multiple drainage techniques available: hypodermic needle instrumentation, intra-sulcal approach (preferable to nail fold incision), or wide incision with scalpel 4, 7, 8
  • Oral antibiotics usually not needed if adequate drainage is achieved, unless patient is immunocompromised or severe infection is present 3, 4
• For ingrown toenail with paronychia: Use dental floss nail technique to separate lateral nail edge from underlying tissue 1
• For excessive granulation tissue: Apply silver nitrate chemical cauterization 6, 1
• Consider partial nail avulsion for intolerable Grade 2 or Grade 3 cases 6

Chronic Paronychia Management (≥6 weeks duration)

Chronic paronychia represents an irritant contact dermatitis rather than infection:

• High-potency topical corticosteroids are first-line treatment and more effective than antifungals 6, 2, 5
• Identify and eliminate irritants (acids, alkalis, chemicals from occupational exposures) 2, 4, 5
• Regular application of emollients to cuticles and periungual tissues 6, 2
• Consider topical calcineurin inhibitors as alternative to steroids 4
• For recurrent/refractory cases: Intralesional triamcinolone acetonide OR topical timolol 0.5% gel twice daily under occlusion for 1 month 6, 1
• Surgical options for recalcitrant cases: En bloc excision of proximal nail fold or eponychial marsupialization 5

Prevention of Recurrence

Patient education is paramount to prevent recurrence:

• Nail care: Trim nails straight across, not too short; avoid biting nails 6, 1
• Avoid trauma: Minimize repeated friction, trauma, and excessive pressure 6, 1
• Protective measures: Wear gloves during water/chemical exposure; wear comfortable well-fitting shoes and cotton socks 6, 1, 2
• Keep hands and feet dry and moisturize regularly 2
• For high-risk patients: Consider referral to podiatrist for preventive correction of nail curvature 6

Common Pitfalls to Avoid

• Do not prescribe oral antibiotics for simple acute paronychia without attempting conservative management first—soaks and topical therapy are often sufficient 1, 3, 4
• Do not miss an abscess—if pus is present, drainage is mandatory and antibiotics alone will fail 1, 2, 4
• Do not treat chronic paronychia with antifungals as first-line—topical corticosteroids are more effective 2, 5
• Do not overlook secondary fungal/bacterial superinfection—present in up to 25% of cases, obtain cultures when appropriate 6, 1, 3

Follow-up Protocol

• Reassess after 2 weeks of treatment (either by healthcare professional or patient self-report) 6, 2, 3
• If no improvement: Consider referral to dermatology or podiatry for further evaluation 1, 2, 3
• For chronic paronychia: Treatment may take weeks to months; set appropriate expectations 4, 5