What is the treatment for paronychia?

Treatment of Paronychia

For mild paronychia, start with warm water or white vinegar soaks 3-4 times daily combined with topical 2% povidone-iodine twice daily and high-potency topical corticosteroids; escalate to oral antibiotics for moderate cases, and consider surgical drainage for severe cases with abscess formation. 1, 2

Initial Assessment

Evaluate the severity by examining for:

• Degree of erythema, edema, and tenderness 1, 2
• Presence of purulent discharge or abscess formation requiring drainage 1, 2
• Associated ingrown toenail (onychocryptosis) which requires specific management 1, 2
• Duration of symptoms to distinguish acute (days to weeks) versus chronic (≥6 weeks) paronychia 3

Treatment Algorithm by Severity Grade

Grade 1 (Mild) Paronychia

Topical therapy is first-line:

• Implement warm water soaks for 15 minutes 3-4 times daily, or alternatively use white vinegar soaks (1:1 white vinegar:water ratio) for 15 minutes daily 4, 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 4, 1, 2
• Use mid to high-potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Continue current activities without restriction if tolerable 4

Important caveat: Grade 1 can escalate to Grade 2 very quickly, so patients must alert healthcare providers at first signs of worsening 4

Grade 2 (Moderate) Paronychia

Combination therapy with consideration for dose modification if drug-induced:

• Start oral antibiotics targeting Staphylococcus aureus and Streptococcus species 1, 3
• Apply topical very potent steroids combined with topical antibiotics and/or antiseptics (preferably as combination preparations) 4, 1
• Continue antiseptic soaks with dilute vinegar or povidone-iodine 2
• If no improvement, refer to dermatology or podiatry for further assessment 4, 1
• For chemotherapy-induced paronychia, consider dose reduction or interruption until resolved (consult drug-specific guidelines) 4

Silver nitrate application: Apply weekly by healthcare professional only if over-granulation tissue has developed 4, 1

Grade 3 (Severe) Paronychia

Aggressive intervention required:

• Swab any purulent discharge for bacterial, viral, and fungal cultures to identify resistant organisms 1, 5
• Prescribe appropriate oral antibiotics based on culture results and local resistance patterns 1, 3
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics 4, 1
• Surgical drainage is mandatory for abscess formation - options range from needle instrumentation to wide incision with scalpel 3, 6
• Consider partial nail plate avulsion for intolerable cases or those with pyogenic granuloma 4, 2
• For chemotherapy-induced cases, discontinue the causative agent and only reinstate when resolved to Grade 2 4

Special Clinical Scenarios

Chronic Paronychia (≥6 weeks duration)

This represents an irritant contact dermatitis rather than infection:

• High-potency topical corticosteroids are more effective than antifungals and should be first-line 1, 2
• Identify and eliminate irritant exposures (acids, alkalis, excessive moisture) 3
• Consider intralesional triamcinolone acetonide for recalcitrant cases 1, 2
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases 4, 2
• Treatment may require weeks to months 3

Critical distinction: Secondary bacterial or mycological superinfections occur in up to 25% of chronic cases, so culture if not improving 1, 2, 5

Treatment Failure After Initial Antibiotics

If cephalexin or initial antibiotic fails:

• Obtain bacterial, viral, and fungal cultures immediately 5
• Switch to broader spectrum coverage such as sulfamethoxazole-trimethoprim (covers MRSA) 5
• Intensify topical therapy with povidone-iodine 2% twice daily plus high-potency corticosteroids 5
• Reassess for surgical intervention if no improvement after 2 weeks 5

Paronychia with Ingrown Toenail

Address the underlying mechanical problem:

• Dental floss nail technique to separate lateral nail edge from underlying tissue 2
• Silver nitrate chemical cauterization for excessive granulation tissue 4, 2
• Partial nail avulsion may be necessary for definitive treatment 2

Common pitfall: Systemic antibiotics are ineffective for ingrown toenail-associated paronychia unless proven infection exists 7

Prevention of Recurrence

Patient education is paramount to prevent recurrence:

• Keep hands and feet as dry as possible; avoid prolonged soaking without protection 4, 2
• Avoid nail trauma, biting nails, or cutting nails too short 4
• Trim nails straight across, not curved 4, 2
• Apply emollients daily to cuticles and periungual tissues 4, 1, 2
• Wear cotton gloves underneath washing gloves during wet work 4, 2
• Wear comfortable, well-fitting shoes that protect but don't restrict nails 4, 2
• Avoid exposure to skin irritants and chemicals 4, 2

Follow-Up Protocol

• Reassess after 2 weeks of treatment 1, 2, 5
• If no improvement, refer to dermatology or podiatry for specialized evaluation 1, 2, 5
• Monitor for pyogenic granuloma development, which may require scoop shave removal with hyfrecation 2

Critical Pitfalls to Avoid

• Do not use systemic antibiotics routinely - they are unnecessary if adequate drainage is achieved unless the patient is immunocompromised or severe infection is present 3, 7
• Do not overlook fungal or atypical infections - secondary colonization occurs in 25% of cases 1, 2, 7
• Do not ignore chronic cases - investigate for unusual causes including malignancy if unresponsive to standard treatment 6
• Do not forget drug-induced causes - chemotherapy and targeted therapies (EGFR inhibitors, taxanes) are common culprits requiring dose modification 4