What is the treatment for acute paronychia?

Treatment of Acute Paronychia

For acute paronychia, begin with antiseptic soaks using dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily, combined with topical 2% povidone-iodine applied directly to the affected area twice daily. 1

Initial Conservative Management (First-Line)

Topical Antiseptic Therapy

• Implement warm antiseptic soaks with either dilute vinegar (50:50 dilution with water) or povidone-iodine solution for 10-15 minutes twice daily. 1
• Apply topical 2% povidone-iodine directly to the affected periungual area twice daily, which has demonstrated benefit in controlled studies. 2, 1

Anti-Inflammatory Treatment

• Apply mid to high-potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation. 1
• For self-limited lesions, high-potency topical corticosteroids can be used alone or combined with topical antibiotics. 2

Adjunctive Measures

• Apply topical emollients regularly to cuticles and periungual tissues to maintain barrier function. 2, 1
• Consider taping with stretchable tapes to reduce mechanical irritation. 2

When to Escalate Treatment

Presence of Abscess

• Assess carefully for pus or abscess formation, which mandates drainage regardless of other treatments. 1, 3
• Drainage options range from simple needle instrumentation (using 23G or 21G needle to lift the nail fold) to wider incision with scalpel depending on abscess size. 3, 4
• Early drainage combined with antibiotics provides pain relief and normal finger function within 2 days. 4

Oral Antibiotic Indications

• Oral antibiotics are indicated for moderate to severe infections, immunocompromised patients, or when adequate drainage cannot be achieved. 1, 3
• Start with cephalexin as first-line oral antibiotic therapy. 5
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA. 1, 6
• Be aware that secondary bacterial or fungal superinfections occur in up to 25% of cases, which may require culture-directed therapy. 1, 6

Special Situations

Pyogenic Granuloma Formation

• Monitor closely for early development of pyogenic granuloma, which can complicate paronychia. 2
• Treat with scoop shave removal with hyfrecation or silver nitrate chemical cauterization. 1, 5
• Topical timolol 0.5% gel applied twice daily under occlusion for 1 month has shown complete clearance in some cases. 2, 5

Severe or Intolerable Cases

• For intolerable grade 2 or grade 3 paronychia, surgical treatment with partial nail plate avulsion may be necessary. 2
• Consider intralesional triamcinolone acetonide for recurrent, severe, or treatment-refractory cases. 1, 5

Treatment Failure Protocol

If No Improvement After 2 Weeks

• Obtain bacterial, viral, and fungal cultures to identify resistant organisms or non-bacterial causes. 6
• Switch to a different antibiotic class based on culture results or broader empiric coverage if cultures are pending. 6
• Consider referral to dermatology or podiatry for further evaluation. 1, 6

Prevention of Recurrence

Patient Education Essentials

• Trim nails straight across and not too short to prevent nail plate trauma to the periungual tissue. 2, 1
• Avoid biting nails, cutting cuticles, or any trauma to the nail fold area. 2
• Wear protective gloves during activities involving water, cleaning chemicals, or repetitive hand work. 2, 1
• Use comfortable, well-fitting shoes and cotton socks to reduce pressure and friction on toenails. 2, 1
• Keep hands dry and avoid prolonged water exposure. 6

Common Pitfalls to Avoid

• Do not prescribe oral antibiotics without first assessing for abscess that requires drainage—antibiotics alone will fail if pus is present. 3
• Do not assume all paronychia is infectious; chronic cases may represent irritant contact dermatitis requiring different management. 3, 7
• Do not overlook underlying conditions such as ingrown toenail (onychocryptosis), which requires specific correction techniques. 1