What is the recommended treatment for paronychia?

Treatment of Paronychia

For acute paronychia, start with warm water or white vinegar soaks 3-4 times daily combined with topical povidone-iodine and mid-to-high potency topical steroids; reserve oral antibiotics only for moderate-to-severe infections or when adequate drainage cannot be achieved. 1, 2

Initial Assessment

Evaluate the severity by examining for redness, edema, discharge, granulation tissue, and presence of pus or abscess formation. 1, 3 Check for predisposing factors including ingrown toenails (onychocryptosis) which require specific management approaches. 1, 3

Treatment Algorithm by Severity Grade

Grade 1 (Mild) Paronychia

• Implement warm water soaks for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 white vinegar:water dilution) for 15 minutes daily. 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area. 1, 3, 2
• Use mid-to-high potency topical steroid ointment to nail folds twice daily to reduce inflammation. 1, 2
• Continue current dose of EGFR-TKI if applicable, but monitor closely as progression to Grade 2 can occur rapidly. 4

Grade 2 (Moderate) Paronychia

• Start oral antibiotics if signs of infection are present; preferred agents include cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours). 2
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA. 2 Avoid clindamycin due to inadequate streptococcal coverage and increasing resistance patterns. 2
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics, preferably as combination preparations. 4, 1
• Apply silver nitrate weekly (by healthcare professional only) if over-granulation tissue has developed. 4, 3
• Consider dose reduction or interruption of EGFR-TKI if applicable until resolved. 4
• Refer to dermatologist if no improvement occurs, or consult podiatrist for foot-related symptoms. 4

Grade 3 (Severe) Paronychia

• Swab any pus for culture and prescribe appropriate antibiotics based on culture results. 1, 2
• Consider surgical intervention for drainage or partial nail avulsion. 1, 3
• Discontinue EGFR-TKI if applicable and only reinstate when resolved to Grade 2. 4
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics as combination preparations. 4, 1
• Apply silver nitrate if over-granulation is present. 4, 3
• Refer for specialist support. 4

Special Considerations for Chronic Paronychia

For chronic paronychia (symptoms ≥6 weeks), high-potency topical corticosteroids are more effective than antifungals. 1, 5 This condition represents an irritant dermatitis rather than primarily infectious etiology. 6, 5

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics. 3
• Regular application of emollients to cuticles and periungual tissues is essential. 1, 3
• Consider intralesional triamcinolone acetonide for recalcitrant cases. 1, 3
• Topical timolol 0.5% gel twice daily under occlusion has shown benefit in some cases. 1, 3

Critical Pitfalls to Avoid

Be aware that up to 25% of paronychia cases have secondary bacterial or mycological superinfections. 1, 2 This is commonly overlooked and can lead to treatment failure. 1

• Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present. 2, 6
• Bacterial cultures should be obtained before starting antibiotics, especially in severe cases or treatment failures. 2
• Do not use systemic antibiotics routinely for paronychia associated with ingrown toenails unless infection is proven. 7

Prevention of Recurrence

• Keep hands and feet as dry as possible; avoid prolonged soaking in water without adequate protection. 4, 1, 3
• Trim nails straight across and not too short to avoid nail trauma. 1, 3
• Moisturize hands and feet regularly with emollients applied to cuticles and periungual tissues. 1, 3
• Wear protective gloves (cotton gloves underneath washing gloves) during wet work or exposure to irritants. 4, 1, 3
• Wear comfortable well-fitting shoes that protect nails without being restrictive. 4, 1, 3
• Dry feet carefully before putting on shoes. 4

Follow-up Protocol

Reassess after 2 weeks of treatment. 1, 3, 2 If no improvement is seen, consider referral to dermatology or podiatry for further evaluation. 1, 3, 2 For patients with chronic paronychia unresponsive to standard treatment, investigate for unusual causes including malignancy. 8