Treatment of Paronychia in Type 2 Diabetes
Paronychia in diabetic patients requires immediate drainage if an abscess is present, followed by topical or oral antibiotics based on infection severity, with meticulous attention to preventing progression to serious complications that can threaten the limb. 1, 2
Immediate Assessment
- Evaluate for signs of infection including erythema, warmth, swelling, purulent drainage, or systemic symptoms that mandate urgent intervention 1, 3
- Assess diabetic foot risk category by checking for peripheral neuropathy (loss of protective sensation), peripheral arterial disease, foot deformities, and history of prior ulceration or amputation 1
- Check vascular status before any surgical intervention, as poor circulation impairs healing and increases infection risk 1
Treatment Algorithm
For Acute Paronychia Without Abscess:
- Start with warm soaks using Burow solution or 1% acetic acid 2
- Apply topical antibiotics with or without topical steroids if simple soaks fail to relieve inflammation within 24-48 hours 2
- Consider topical antifungal coverage since Candida species frequently coexist with paronychia in diabetic patients, particularly in skin folds 4, 5
For Acute Paronychia With Abscess:
- Drainage is the most important intervention and must be performed immediately 4, 2
- Drainage options range from instrumentation with a hypodermic needle to wide incision with a scalpel 2
- Obtain cultures from tissue specimens at the base of the lesion (not swabs) before starting antibiotics 3
- Prescribe oral antibiotics after drainage if the patient is immunocompromised (which includes diabetics with poor glycemic control) or if severe infection is present 2, 6
- Base antibiotic selection on most likely pathogens (Staphylococcus aureus, Streptococcus species, polymicrobial) and local resistance patterns 2, 6
For Chronic or Recurrent Paronychia:
- Professional nail care by a trained healthcare professional, including proper trimming of the ingrown portion, removal of excess callus, and careful debridement of the nail border 1
- Topical combination therapy with an insulating polymer barrier, antifungals (octopirox and climbazole), and anti-inflammatory agents applied three times daily for 2 months 7
- Add oral fluconazole 100 mg for 20 days if severe Candida infection is proven 7
- Consider surgical intervention (partial or complete nail avulsion) for cases that don't respond to conservative treatment 1
Special Considerations for Diabetic Patients
- Never delay treatment as paronychia can rapidly progress to serious hand or foot ulcers, potentially leading to amputation or death in diabetic patients 1, 6
- Avoid prophylactic antibiotics for uninfected paronychia, as this promotes antibiotic resistance without benefit 3
- Prohibit self-treatment by patients, especially those with neuropathy who may not recognize worsening infection 1
- Screen for onychomycosis as approximately 34% of diabetics have fungal nail infections that predispose to paronychia and require systemic antifungal therapy 8, 5
Prevention and Patient Education
- Instruct on proper nail trimming technique: cut straight across, not too short, to prevent ingrown nails 1
- Educate on daily foot inspection and immediate reporting of any new lesions or signs of infection 1, 3
- Recommend appropriate footwear that accommodates foot shape and fits properly 1, 3
- Emphasize keeping affected areas dry, as moisture promotes both bacterial and fungal growth 4
- Advise against barefoot walking or wearing inappropriate footwear 1
Follow-Up Schedule
- Schedule visits every 1-3 months for high-risk diabetic patients (those with neuropathy, peripheral arterial disease, or history of ulceration) 1
- Provide integrated foot care including professional foot treatment, adequate footwear, and structured education about self-care 1, 3
- Monitor for fungal infections that often coexist with paronychia in diabetic patients and treat appropriately 3, 5