What is the treatment for paronychia?

Treatment of Paronychia

For mild paronychia, start with warm water or white vinegar soaks 3-4 times daily combined with topical 2% povidone-iodine twice daily and high-potency topical corticosteroids; escalate to oral antibiotics for moderate cases, and consider surgical drainage for severe cases with abscess formation. 1, 2

Initial Assessment

Evaluate the severity by examining for:

• Degree of erythema, edema, and tenderness 1, 2
• Presence of purulent discharge or abscess formation requiring drainage 1, 2
• Associated ingrown toenail (onychocryptosis) that may need specific intervention 1, 2
• Duration of symptoms to distinguish acute (days to weeks) from chronic (≥6 weeks) paronychia 3

Treatment Algorithm by Severity Grade

Grade 1 (Mild) Paronychia

Conservative measures are first-line:

• Implement warm water soaks for 15 minutes 3-4 times daily, or alternatively use white vinegar soaks (1:1 white vinegar:water ratio) for 15 minutes daily 4, 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 4, 1, 2
• Use mid to high-potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Continue current medications without dose adjustment if paronychia is drug-related 4

Critical pitfall: Grade 1 can escalate to Grade 2 very quickly, so patients must alert healthcare providers at first signs of worsening 4

Grade 2 (Moderate) Paronychia

Escalate treatment with systemic therapy:

• Start oral antibiotics targeting likely pathogens (Staphylococcus aureus, Streptococcus species) 4, 1
• Apply topical very potent steroids combined with topical antibiotics and/or antiseptics, preferably as combination preparations 4
• If drug-related, consider dose reduction or interruption until resolved 4
• Apply silver nitrate weekly (by healthcare professional only) if over-granulation tissue has developed 4
• Refer to dermatologist if no improvement occurs 4
• For toenail involvement, consult podiatry 4

Grade 3 (Severe) Paronychia

Aggressive intervention is required:

• Swab any purulent material for culture and sensitivity testing 4, 1
• Prescribe appropriate antibiotics based on culture results or empirically for broader coverage 4, 1
• If initial cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for MRSA coverage 5
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics 4
• Perform surgical drainage for abscess formation 4, 1
• Consider partial nail plate avulsion for intolerable symptoms or pyogenic granuloma 4, 2
• If drug-related, discontinue causative agent and only reinstate when resolved to Grade 2 4

Important consideration: Secondary bacterial or mycological superinfections occur in up to 25% of cases, so obtain cultures to guide therapy 1, 5

Chronic Paronychia (≥6 Weeks Duration)

Chronic cases require different management:

• High-potency topical corticosteroids are more effective than antifungals and should be first-line therapy 1, 6
• Apply topical corticosteroids alone or combined with topical antibiotics 4
• For recalcitrant cases, consider intralesional triamcinolone acetonide 1, 2
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases 4, 2
• Address underlying irritant exposure (water, chemicals, allergens) as chronic paronychia represents an irritant contact dermatitis 3, 6

Special Interventions

For pyogenic granuloma formation:

• Apply silver nitrate chemical cauterization 4, 2
• Consider cryotherapy as an alternative 4
• Scoop shave removal with hyfrecation may be necessary 2

For associated ingrown toenail:

• Use dental floss nail technique to separate lateral nail edge from underlying tissue 2
• Partial nail avulsion may be required for definitive treatment 2

Prevention of Recurrence

Patient education on preventive measures is essential:

• Keep hands and feet as dry as possible; avoid prolonged soaking in soapy water 4, 2
• Avoid nail trauma, biting nails, or cutting nails too short 4, 2
• Trim nails straight across, not too short 4, 2, 5
• Apply emollients daily to cuticles and periungual tissues 4, 1, 2
• Wear protective cotton gloves underneath washing gloves during wet work 4
• Wear comfortable, well-fitting shoes that protect nails without being restrictive 4, 2
• Dry feet carefully before putting on shoes 4
• Avoid exposure to skin irritants 4, 2

Follow-Up and Monitoring

• Reassess after 2 weeks of treatment 1, 2, 5
• If no improvement, refer to dermatology or podiatry for further evaluation 1, 2, 5
• Monitor closely for early symptoms of pyogenic granuloma development 4

Common Pitfalls to Avoid

• Don't overlook secondary infections: Up to 25% of cases have bacterial or fungal superinfection requiring culture-directed therapy 1, 5
• Don't delay drainage: Presence of abscess mandates surgical drainage; antibiotics alone are insufficient 1, 2
• Don't ignore rapid progression: Grade 1 can quickly escalate to Grade 2, requiring early patient education about warning signs 4
• Don't treat chronic paronychia with antifungals first: Topical corticosteroids are more effective as chronic paronychia is primarily an inflammatory condition 1, 6