What is the treatment for paronychia?

Treatment of Paronychia

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

Initial Assessment

• Determine if acute versus chronic: Acute presents with painful erythematous inflammation and swelling of the lateral nail folds, while chronic persists for at least 6 weeks and represents an irritant dermatitis 2, 3
• Grade severity using redness, edema, discharge, and granulation tissue as parameters 1, 4
• Check for abscess formation by palpating for fluctuance—if present, drainage is mandatory rather than conservative management alone 4, 5
• Identify predisposing factors including ingrown toenail (onychocryptosis), occupational exposures to irritants, or medication-induced causes (particularly EGFR inhibitors in cancer patients) 1
• Note that secondary bacterial or fungal superinfection occurs in up to 25% of cases, so consider culture if not responding to initial therapy 1

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

• Continue with antiseptic soaks: Warm water for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 white vinegar:water) for 15 minutes daily 1
• Apply topical 2% povidone-iodine twice daily to the affected area 1
• Use mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 4, 5
• Monitor closely as Grade 1 can escalate to Grade 2 very quickly 1

Grade 2 (Moderate) Paronychia

• Start oral antibiotics targeting likely pathogens (Staphylococcus aureus and Streptococcus species): cephalexin or amoxicillin-clavulanate as first-line 4, 6
• If initial antibiotic fails, switch to sulfamethoxazole-trimethoprim for broader coverage including MRSA 4
• Apply topical very potent steroids combined with topical antibiotics (preferably as combination preparations) 1
• Apply silver nitrate weekly (by healthcare professional only) if over-granulation tissue has developed 1
• Consider dose reduction or interruption of causative medications (e.g., EGFR inhibitors) if drug-induced 1
• Refer to dermatologist or podiatrist if no improvement after initial treatment 1

Grade 3 (Severe) Paronychia

• Swab any purulent discharge for culture and prescribe appropriate antibiotics based on sensitivities 1
• Perform surgical drainage if abscess is present—options range from needle instrumentation to incision with scalpel 2, 7
• Consider partial nail plate avulsion for intolerable symptoms or pyogenic granuloma formation 1
• Continue topical very potent steroids, antifungals, and antibiotics as combination therapy 1
• Discontinue causative medications (if drug-induced) and only reinstate when resolved to Grade 2 1
• Refer for specialist surgical support for definitive management 1

Chronic Paronychia Management

High-potency topical corticosteroids are more effective than antifungals for chronic paronychia and should be first-line treatment. 6, 3

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 1
• Consider intralesional triamcinolone acetonide for recalcitrant cases 4, 5
• Topical timolol 0.5% gel twice daily under occlusion has shown complete clearance in some cases after 1 month 1
• Identify and eliminate irritants: acids, alkalis, chemicals, excessive moisture exposure 2, 3
• Regular application of emollients to cuticles and periungual tissues 1
• Surgical options for refractory cases: en bloc excision of proximal nail fold or eponychial marsupialization 3

Special Considerations for Pyogenic Granuloma

• Perform scoop shave removal with hyfrecation or silver nitrate application 4
• Cryotherapy can also be considered for treatment 1

Prevention of Recurrence

• Keep hands and feet as dry as possible—avoid prolonged soaking in soapy water without adequate protection 1
• Trim nails straight across and not too short—avoid cutting into corners 1
• Apply emollients daily to cuticles and periungual tissues 1
• Wear protective gloves during wet work or exposure to chemicals (cotton gloves underneath washing-up gloves) 1
• Wear comfortable, well-fitting shoes and cotton socks that protect nails without being restrictive 1
• Avoid nail trauma, biting nails, and exposure to skin irritants 1
• Refer to podiatrist for preventive correction of nail curvature if needed 1

Follow-up Protocol

• Reassess after 2 weeks of treatment 1
• If no improvement, refer to dermatology or podiatry for further evaluation and consideration of alternative diagnoses 4, 5
• If worsening despite treatment, consider culture for atypical organisms and investigate for unusual causes such as malignancy in chronic cases 7

Common Pitfalls to Avoid

• Don't overlook secondary bacterial or fungal superinfection present in up to 25% of cases—culture if not responding 1
• Don't prescribe oral antibiotics alone without adequate drainage if an abscess is present—drainage is mandatory 4, 2
• Don't use antifungals as first-line for chronic paronychia—topical corticosteroids are more effective 6, 3
• Don't ignore medication-induced causes particularly in patients on EGFR inhibitors or taxane chemotherapy 1