What is the treatment for paronychia?

Treatment for Paronychia

For mild to moderate paronychia, start with conservative management using antiseptic soaks (dilute vinegar or povidone-iodine) twice daily combined with high-potency topical corticosteroids, reserving oral antibiotics for suspected bacterial infection or treatment failure. 1

Initial Assessment

Evaluate the severity of paronychia by assessing four key parameters: redness, edema, discharge, and presence of granulation tissue 1. Check specifically for abscess formation requiring drainage, and identify any underlying ingrown toenail (onychocryptosis) that may be perpetuating the condition 1. Be aware that secondary bacterial or fungal superinfection occurs in up to 25% of cases, which may alter your treatment approach 2, 1.

Conservative Management (First-Line for Grade 1-2)

Antiseptic Soaks and Topical Therapy

• Implement antiseptic soaks with either dilute vinegar (50:50 dilution with water) or povidone-iodine for 10-15 minutes twice daily 1
• Apply topical 2% povidone-iodine directly to the affected area twice daily 1
• Use mid to high-potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation 1
• Apply emollients regularly to cuticles and periungual tissues 2, 1

This conservative approach should be the initial treatment for all mild to moderate cases before escalating therapy. 1, 3

Antimicrobial Therapy

When to Add Antibiotics

For moderate to severe infection with signs of bacterial involvement (purulent discharge, significant warmth, spreading erythema), oral antibiotics are indicated 1.

Antibiotic Selection

• First-line: Cephalexin for typical bacterial pathogens 4
• If cephalexin fails or MRSA suspected: Switch to sulfamethoxazole-trimethoprim (Bactrim), which provides broader coverage including MRSA and both gram-positive and gram-negative organisms 4

A critical pitfall is continuing ineffective antibiotics—if paronychia worsens on cephalexin, immediately switch to Bactrim rather than prolonging inadequate therapy. 4

Culture Guidance

Obtain bacterial, viral, and fungal cultures when infection is suspected, particularly if initial treatment fails, to identify resistant organisms or non-bacterial causes 4.

Advanced Topical Options

For self-limited lesions not responding to initial conservative management, consider 2:

• High-potency topical corticosteroids combined with topical antibiotics 2
• Silver nitrate chemical cauterization for excessive granulation tissue 1
• Taping with stretchable tapes 2
• Topical timolol 0.5% gel twice daily under occlusion for one month (particularly effective for drug-induced paronychia with pyogenic granulomas) 2, 1

Surgical Interventions

Indications for Surgery

For intolerable grade 2 or grade 3 paronychia with pyogenic granuloma formation, surgical treatment with partial nail plate avulsion is indicated. 2

Surgical Techniques

• For paronychia with ingrown toenail: dental floss nail technique to separate the lateral nail edge from underlying tissue 1
• For pyogenic granuloma: scoop shave removal with hyfrecation or silver nitrate application 1
• For recurrent or treatment-refractory cases: consider intralesional triamcinolone acetonide 1
• Cryotherapy may be considered for pyogenic granuloma 2

Chronic Paronychia Management

Chronic paronychia (symptoms ≥6 weeks) represents an irritant dermatitis rather than primarily infectious process 5. Treatment focuses on:

• Identifying and eliminating irritant exposures (chemicals, excessive moisture) 5
• High-potency topical corticosteroids as primary therapy 6, 5
• Topical calcineurin inhibitors as alternative anti-inflammatory agents 5
• Protective measures including gloves during water/chemical exposure 1

Treatment may take weeks to months for chronic paronychia, and patient education about irritant avoidance is paramount to prevent recurrence. 5

Prevention of Recurrence

• Trim nails straight across and not too short 2, 1
• Avoid repeated friction, trauma, and excessive pressure 2
• Wear comfortable well-fitting shoes and cotton socks 2
• Use protective gloves during activities involving water or chemicals 1
• Avoid nail biting and cutting nails too short 2
• Consider referral to podiatrist for preventive correction of nail curvature 2

Follow-up and Specialist Referral

Reassess after 2 weeks of appropriate treatment. 1, 3 If no improvement is seen, refer to dermatology or podiatry (not general surgery) for further evaluation 3. Dermatology and podiatry are the appropriate specialists for paronychia management, with hand surgery reserved only for severe or treatment-refractory finger paronychia requiring advanced surgical intervention 3.

A common pitfall is reflexive general surgery referral—paronychia is managed primarily by dermatology and podiatry given their expertise in nail fold pathology. 3