What is the treatment for paronychia?

Treatment of Paronychia

Treat paronychia based on severity grading: mild cases respond to warm soaks and topical steroids, moderate cases require oral antibiotics, and severe cases with abscess formation mandate surgical drainage. 1, 2

Initial Assessment

Evaluate severity using these parameters to guide treatment decisions 1, 2:

• Redness, edema, discharge, and granulation tissue presence 1
• Check specifically for pus or abscess formation - this finding changes management from conservative to surgical 1, 2
• Identify predisposing factors including ingrown toenails, occupational water exposure, or medication-induced causes 2

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

Start with antiseptic soaks and topical anti-inflammatory therapy 1, 2:

• Warm water soaks for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 white vinegar:water ratio) for 15 minutes daily 1, 3
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 3
• Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 3

Grade 2 (Moderate) Paronychia

Escalate to systemic antibiotics when signs of infection are present 1, 2:

• Start oral antibiotics: preferred agents are cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) 2, 3
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 3
• Avoid clindamycin - it lacks adequate streptococcal coverage and has increasing resistance patterns 3
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 1, 2

Grade 3 (Severe) Paronychia

Surgical drainage is mandatory when abscess is present 1, 2:

• Swab any pus for culture before starting antibiotics 1, 3
• Perform surgical drainage - options range from instrumentation with hypodermic needle to wide incision with scalpel 1, 4
• Prescribe appropriate antibiotics based on culture results 3
• Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 3, 4

Chronic Paronychia Management

High-potency topical corticosteroids are more effective than antifungals for chronic paronychia and should be first-line treatment 1, 2, 5:

• Apply high-potency topical corticosteroids as primary therapy 1, 5
• Consider intralesional triamcinolone acetonide for recalcitrant cases 1
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases 1
• Regular application of emollients to cuticles and periungual tissues 2
• Identify and eliminate irritants - common culprits include acids, alkalis, and chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 4

Critical Pitfall to Avoid

Do not overlook secondary bacterial or mycological superinfections, which are present in up to 25% of cases 1, 3:

• Obtain bacterial cultures before starting antibiotics, especially in severe cases or treatment failures 3
• Mixed infections with bacteria, fungus, and yeast are common in chronic paronychia 6

Prevention of Recurrence

Implement these measures to prevent recurrence 1, 2:

• Keep hands and feet as dry as possible - avoid prolonged soaking in water 1, 2
• Avoid nail trauma/injury and cutting nails too short 1, 2
• Moisturize hands and feet regularly with emollients applied to cuticles and periungual tissues 1, 2
• Wear protective gloves during wet work or exposure to irritants 1, 2
• Wear comfortable well-fitting shoes that protect nails without being restrictive 1, 2

Follow-up Protocol

Reassess after 2 weeks of treatment 1, 3:

• If no improvement is seen, refer to dermatology or podiatry for further evaluation 1, 3
• Treatment for chronic paronychia may take weeks to months 4