Best Antibiotic for Paronychia
For acute bacterial paronychia, dicloxacillin 250 mg four times daily or cephalexin 250 mg four times daily are the first-line antibiotics, targeting Staphylococcus aureus. 1
Acute Bacterial Paronychia Treatment Algorithm
First-Line Antibiotic Selection
- Dicloxacillin 250 mg four times daily is the preferred first-line agent for acute bacterial paronychia 1
- Cephalexin 250 mg four times daily serves as an equally effective alternative first-line option 1
- Both agents target Staphylococcus aureus, the most common pathogen in acute paronychia 2, 3
Penicillin-Allergic Patients
- Clindamycin 300-400 mg three times daily should be used in patients with penicillin allergy 1
- This also provides coverage for anaerobic organisms, which is particularly relevant in pediatric patients with finger-sucking habits 3
MRSA Coverage
- Trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily) or doxycycline (100 mg twice daily) should be selected when MRSA is suspected 1
- MRSA should be considered in cases with treatment failure, severe infection, or known community prevalence 3
Important Clinical Caveats
When Antibiotics Are NOT Needed
- Oral antibiotics are usually unnecessary if adequate drainage is achieved, unless the patient is immunocompromised or has severe infection 2
- Simple warm soaks with or without Burow solution or 1% acetic acid may suffice for early infections without abscess formation 2
- Topical antibiotics with or without topical steroids can be used when simple soaks fail to relieve inflammation 2
Abscess Management Takes Priority
- The presence of an abscess mandates drainage, which is the definitive treatment 2, 4
- Drainage options range from instrumentation with a hypodermic needle to wide incision with a scalpel 2
- For paronychia not associated with ingrown toenail, an intra-sulcal approach is preferable to a nail fold incision 4
Chronic Paronychia: A Different Entity
Key Distinction
- Chronic paronychia (≥6 weeks duration) is primarily an irritant contact dermatitis, NOT an infection 2
- Systemic antibiotics should NOT be used routinely for chronic paronychia 5
Appropriate Treatment for Chronic Cases
- Mid to high potency topical steroids are the preferred first-line treatment to reduce inflammation 1
- Topical povidone iodine 2% twice daily has demonstrated benefit in controlled studies 6, 1
- If Candida infection is confirmed, itraconazole is first-line antifungal treatment, with fluconazole as an alternative 6, 1
Culture-Guided Therapy
- Culture should be obtained in treatment failures to guide antibiotic selection based on sensitivity patterns 1
- Pediatric patients with oral self-soothing behaviors may harbor mixed anaerobic and aerobic infections, warranting initial broad-spectrum coverage with amoxicillin/clavulanate or clindamycin 3
Common Pitfalls to Avoid
- Do not prescribe systemic antibiotics for ingrown toenail-associated paronychia unless infection is proven 5
- Do not miss drug-induced paronychia from EGFR inhibitors in cancer patients, which requires different management approaches (topical corticosteroids, not antibiotics) 6, 1
- Do not treat chronic paronychia as a bacterial infection—it is an inflammatory condition requiring anti-inflammatory therapy, not antibiotics 2, 5