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) which requires specific management 1, 2
• Duration of symptoms to distinguish acute (days to weeks) versus chronic (≥6 weeks) paronychia 3

Treatment Algorithm by Severity Grade

Grade 1 (Mild) Paronychia

Topical therapy is 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 activities without restriction 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

Combination therapy with consideration for dose modification if drug-induced:

• Start oral antibiotics if signs of infection are present 4, 1
• Apply topical very potent steroids combined with topical antibiotics and/or antiseptics (preferably as combination preparations) 4, 1
• Continue antiseptic soaks with dilute vinegar or povidone-iodine 2
• Apply silver nitrate weekly (by healthcare professional only) if over-granulation tissue has developed 4
• Consult podiatry for foot-related symptoms 4
• Consider dose reduction or interruption of causative medications (e.g., EGFR inhibitors) until resolved 4

If no improvement: Refer to dermatology for further assessment 4

Grade 3 (Severe) Paronychia

Aggressive intervention required:

• Swab any purulent discharge for culture and sensitivity testing 4, 1
• Prescribe appropriate antibiotics based on culture results or empirically for likely pathogens 4, 1
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics 4
• Apply silver nitrate if over-granulation is present 4
• Consider surgical intervention for drainage or partial nail avulsion 4, 1, 2
• Discontinue causative medications and only reinstate when resolved to Grade 2 4
• Refer for specialist support 4

Special Clinical Scenarios

Chronic Paronychia (≥6 weeks duration)

This represents an irritant dermatitis rather than infection:

• Apply high-potency topical corticosteroids, which are more effective than antifungals in chronic cases 1, 2
• Consider intralesional triamcinolone acetonide for recalcitrant cases 1, 2
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases 4, 2
• Treatment may take weeks to months 3

Important caveat: Secondary bacterial or mycological superinfections are present in up to 25% of cases, so consider cultures if not improving 1, 2, 5

Paronychia Not Responding to Initial Antibiotics (e.g., Cephalexin)

Systematic approach to treatment failure:

• Obtain bacterial, viral, and fungal cultures to identify resistant organisms 5
• Switch to broader spectrum coverage such as sulfamethoxazole-trimethoprim (Bactrim) which covers MRSA 5
• Intensify topical therapy with povidone-iodine 2% twice daily combined with high-potency topical corticosteroids 5
• Consider silver nitrate chemical cauterization for excessive granulation tissue 5
• In severe cases with significant inflammation, partial nail avulsion may be necessary 5
• Reassess after 2 weeks; if no improvement, refer to dermatology or hand surgery 5

Paronychia with Pyogenic Granuloma

Specific management required:

• Perform scoop shave removal with hyfrecation or silver nitrate application 2
• Cryotherapy can also be considered 4
• Monitor closely as patients on EGFR inhibitors are at particular risk 4

Prevention of Recurrence

Patient education is paramount:

• Keep hands and feet as dry as possible; avoid prolonged soaking in soapy water without adequate protection 4, 2
• Avoid nail trauma, injury, and cutting nails too short 4, 1
• Trim nails straight across, not too short, ensuring they remain straight 4, 2
• Apply emollients daily to cuticles and periungual tissues 4, 1, 2
• Wear cotton gloves underneath washing gloves during wet work 4
• Wear comfortable, well-fitting shoes that protect nails without being restrictive 4, 2
• Avoid biting nails and exposure to skin irritants 4
• Consider referral to podiatrist for preventive correction of nail curvature if needed 4

Follow-up Protocol

• Reassess after 2 weeks of treatment 1, 2, 5
• If no improvement, consider referral to dermatology or podiatry for further evaluation 1, 2, 5
• For drug-induced paronychia, monitor closely for early symptoms of pyogenic granuloma 4

Critical Pitfalls to Avoid

• Do not overlook secondary infections: Up to 25% of cases have bacterial or fungal superinfection requiring specific antimicrobial therapy 1, 2, 5
• Do not use systemic antibiotics routinely: They are ineffective unless infection is proven, particularly in chronic paronychia or ingrown toenails without confirmed infection 6
• Do not delay drainage: Presence of abscess mandates surgical drainage; antibiotics alone are insufficient 3, 7
• Do not ignore underlying causes: Chronic paronychia may indicate contact dermatitis, chemical irritants, or rarely malignancy requiring dermatology consultation 3, 7