What is the treatment for paronychia?

Treatment of Paronychia

For acute paronychia, start with warm water soaks 2-3 times daily for 10-15 minutes combined with mid-to-high potency topical corticosteroid ointment to the nail folds twice daily, reserving incision and drainage only for cases with frank abscess formation. 1

Initial Assessment and Classification

Paronychia is an infection or inflammation of the nail fold that must be classified as either acute (symptoms <6 weeks) or chronic (symptoms ≥6 weeks) to guide treatment. 2

Key distinguishing features:

• Acute paronychia is a polymicrobial infection following breach of the protective nail barrier, commonly affecting thumbs and great toes due to repeated trauma 1, 3
• Chronic paronychia represents an irritant contact dermatitis rather than a primarily infectious process, commonly affecting individuals with wet occupations (housekeepers, dishwashers, bartenders, florists, bakers, swimmers) 1, 2
• Up to 25% of cases have secondary bacterial or mycological superinfection requiring culture-directed therapy 1

Treatment Algorithm for Acute Paronychia

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

First-line conservative management:

• Warm water soaks for 10-15 minutes, 2-3 times daily 1
• Alternative: Dilute vinegar soaks (50:50 dilution with water) twice daily 1, 4
• Mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 4
• Topical povidone iodine 2% twice daily (shown benefit in controlled studies) 5, 4
• Reassess after 2 weeks; if no improvement, escalate treatment 5

Critical pitfall: Do not start oral antibiotics empirically at this stage unless there is clear evidence of spreading infection. 2

Grade 2 (Moderate): Pain with discharge or nail plate separation

Continue conservative measures plus:

• Topical povidone iodine 2% combined with topical antibiotics and corticosteroids 5, 4
• Consider topical timolol 0.5% gel twice daily under occlusion if pyogenic granuloma develops (complete clearance reported in 8/8 patients) 5
• Obtain bacterial/viral/fungal cultures if infection is suspected 5
• Oral antibiotics only if cultures indicate infection or conservative treatment fails after 2 weeks 1, 4
• For recurrent or severe cases, consider intralesional triamcinolone acetonide 1

Abscess management: If fluctuance is present, incision and drainage is mandatory. 3, 6 Options range from instrumentation with a hypodermic needle to wide incision with a scalpel, depending on abscess size. 2

Grade 3 (Severe): Limiting self-care activities, surgical intervention indicated

Aggressive intervention required:

• Interrupt causative factors immediately 5
• Obtain bacterial/viral/fungal cultures before starting antibiotics 5, 4
• Parenteral antibiotics for severe infections or immunocompromised patients 3
• Consider partial nail avulsion for intolerable grade 2 or grade 3 cases 5
• Surgical consultation for pyogenic flexor tenosynovitis (a surgical emergency requiring sheath irrigation) 3, 6

Antibiotic selection: Base therapy on most likely pathogens (Staphylococcus aureus, beta-hemolytic streptococci) and local resistance patterns. 7 Consider doxycycline 100 mg twice daily for recurrent, severe, or treatment-refractory cases with 1-month follow-up. 1

Treatment of Chronic Paronychia

The cornerstone is identifying and eliminating irritant exposures, not antibiotics. 2

Specific management:

• Identify occupational or environmental irritants (acids, alkalis, chemicals, excessive water exposure) 1, 2
• Mid-to-high potency topical corticosteroid ointment or calcineurin inhibitors to restore the nail barrier 2
• For Candida-associated chronic paronychia: topical imidazole lotions as first-line; oral itraconazole if nail plate invasion is present 4
• Treatment duration: weeks to months are required for complete resolution 2

Important caveat: Avoid prolonged topical steroid use without addressing the underlying irritant cause, as this leads to treatment failure and recurrence. 4

Prevention Strategies (Essential for All Patients)

Patient education is paramount to prevent recurrence: 1, 2

• Keep hands dry and avoid excessive moisture exposure 1, 4
• Wear protective gloves when working with chemicals or water 1, 4
• Avoid nail-biting, finger-sucking, or cutting nails too short 5, 1
• Trim nails straight across, not too short 5, 4
• Apply daily topical emollients to cuticles and periungual tissues 5, 1
• Wear comfortable, well-fitting shoes and cotton socks 5, 4
• Avoid repeated friction and trauma to nail folds 5
• For associated ingrown nails: dental floss nail splinting, cotton packing, or cast edge separation 1

Special Populations

Immunocompromised patients or those on anticancer therapy:

• Paronychia is common with EGFR inhibitors (17.2% all-grade incidence), MEK inhibitors, and mTOR inhibitors 5
• More aggressive early intervention with topical povidone iodine 2% and close monitoring for pyogenic granuloma development 5
• Lower threshold for surgical intervention in grade 2 disease 5

Herpetic whitlow (herpes simplex virus):

• Do NOT incise and drain (this is a viral infection, not bacterial) 3, 6
• Early treatment with oral antiviral agents may hasten healing 6
• Typically resolves without intervention 3