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:

• Start oral antibiotics targeting Staphylococcus aureus and Streptococcus species 3, 5
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 6
• Apply topical very potent steroids combined with topical antibiotics and/or antiseptics (preferably as combination preparations) 4
• Apply silver nitrate weekly by healthcare professional only if over-granulation tissue has developed 4, 2
• Consider dose reduction or interruption of any causative medications (e.g., EGFR inhibitors) until resolved 4
• Refer to dermatologist if no improvement after 2 weeks 4, 1
• Consult podiatrist for toenail-related symptoms 4

Grade 3 (Severe) Paronychia

Aggressive intervention required:

• Swab any purulent material for bacterial, viral, and fungal cultures before starting antibiotics 1, 6
• Prescribe appropriate antibiotics based on culture results and local resistance patterns 6, 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, 7
• Consider partial nail plate avulsion for intolerable symptoms or pyogenic granuloma 4, 2
• Discontinue any causative medications and only reinstate when resolved to Grade 2 4

Special Clinical Scenarios

Chronic Paronychia (≥6 weeks duration)

This represents an irritant contact dermatitis, not primarily infectious:

• High-potency topical corticosteroids are more effective than antifungals and should be first-line 1, 2
• Identify and eliminate irritant exposures (water, chemicals, detergents) 3, 5
• 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

Paronychia with Pyogenic Granuloma

• Scoop shave removal with hyfrecation or silver nitrate application 2
• Cryotherapy can also be considered 4
• Topical timolol 0.5% gel twice daily under occlusion has demonstrated complete clearance 4, 2

Treatment Failure After Initial Antibiotics

If no improvement after 2 weeks of cephalexin:

• Obtain bacterial, viral, and fungal cultures as secondary infections occur in up to 25% of cases 6, 5
• Switch to broader spectrum coverage such as sulfamethoxazole-trimethoprim 6
• Reassess for adequate drainage - inadequate drainage is a common cause of treatment failure 3, 7
• Consider non-infectious etiologies including contact dermatitis, systemic conditions, or medication side effects 5, 8

Prevention of Recurrence

Patient education is paramount:

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

Common Pitfalls to Avoid

• Do not overlook secondary bacterial or fungal superinfections, which occur in up to 25% of cases and require culture-directed therapy 1, 6, 5
• Do not prescribe systemic antibiotics routinely for chronic paronychia - this is primarily an irritant dermatitis, not an infection 5
• Do not use systemic antibiotics for ingrown toenails unless proven infection - the paronychia is mechanical, not infectious 5
• Do not delay surgical drainage when abscess is present - antibiotics alone are insufficient 3, 7
• Do not perform nail fold incisions - an intra-sulcal approach is preferable for drainage 7