What is the treatment for paronychia?

Treatment of Paronychia

For mild to moderate paronychia (Grade 1-2), start with conservative management using antiseptic soaks twice daily, topical 2% povidone-iodine, and high-potency topical corticosteroids with or without topical antibiotics; if no improvement after 2 weeks, escalate to oral antibiotics or consider specialist referral to dermatology or podiatry—not general surgery. 1, 2

Initial Conservative Management (First-Line for Grade 1-2)

Antiseptic soaks and topical therapy:

• Perform antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 2
• Apply topical 2% povidone-iodine twice daily to the affected area 3, 2
• Use high-potency topical corticosteroid ointment to nail folds twice daily, alone or combined with topical antibiotics 3, 2
• Apply topical emollients daily to cuticles and periungual tissues 3

Additional conservative measures:

• Silver nitrate chemical cauterization for excessive granulation tissue 3, 2
• Taping with stretchable tapes to reduce pressure 3
• For ingrown toenail component, use dental floss nail technique to separate the lateral nail edge from underlying tissue 2

Antimicrobial Therapy

When to add systemic antibiotics:

• Consider oral antibiotics for moderate to severe infection or when conservative measures fail after initial trial 3, 2
• Select antibiotics based on likely pathogens (Staphylococcus aureus, Streptococcus) and local resistance patterns 4
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 2
• Note that secondary bacterial or mycological superinfections occur in up to 25% of cases 3

Important caveat: Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 4

Surgical Intervention

Indications for drainage or surgery:

• Presence of abscess mandates drainage 4
• For intolerable Grade 2 or Grade 3 paronychia/pyogenic granuloma, perform partial nail plate avulsion 3
• Drainage options range from instrumentation with hypodermic needle to wide incision with scalpel 4

For pyogenic granuloma:

• Scoop shave removal with hyfrecation or silver nitrate application 2
• Cryotherapy can also be considered 3
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases 3, 2

Chronic Paronychia Management

Key distinction: Chronic paronychia (≥6 weeks duration) is primarily an irritant dermatitis, not an infection 4, 5

• Stop the source of irritation (acids, alkalis, chemicals, excessive moisture) 4
• High-potency topical corticosteroids or calcineurin inhibitors are the mainstay 4, 5
• Treatment may take weeks to months 4
• In recalcitrant cases, consider intralesional triamcinolone acetonide 2
• Surgical options for severe cases include en bloc excision of proximal nail fold or eponychial marsupialization 5

Prevention Measures

Patient education is paramount to reduce recurrence: 4

• Trim nails straight across and not too short 3, 2
• Avoid biting nails or cutting cuticles 3
• Avoid repeated friction, trauma, and excessive pressure 3
• Wear protective gloves during water exposure or chemical handling 3, 2
• Wear comfortable well-fitting shoes and cotton socks for toenails 3, 2
• Preventive correction of nail curvature with podiatrist referral if needed 3

Follow-up and Specialist Referral

Reassessment timeline:

• Reassess after 2 weeks of conservative management 1, 2
• If no improvement after 2 weeks of appropriate treatment, refer to dermatology or podiatry—not general surgery 1
• Hand surgery consultation is reserved specifically for severe or treatment-refractory finger paronychia requiring advanced surgical intervention 1
• For toenail paronychia with complications, podiatry is the preferred specialty 1

Common Pitfalls to Avoid

• Do not reflexively refer to general surgery—paronychia is managed primarily by dermatology and podiatry 1
• Do not use systemic antibiotics routinely for ingrown nail-associated paronychia unless infection is proven 6
• Do not overlook chronic paronychia as infection—it is primarily inflammatory/irritant dermatitis requiring steroids, not antibiotics 4, 5
• Do not forget to address underlying predisposing factors such as onychocryptosis or occupational irritant exposure 2, 4