What is the treatment for paronychia?

Treatment of Paronychia

For mild paronychia, start with warm water 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 with clear signs of bacterial involvement. 1, 2

Initial Assessment

Before initiating treatment, determine the following key parameters:

• Severity grading based on redness, edema, presence of discharge, granulation tissue, and abscess formation 1, 2
• Acute versus chronic presentation (chronic defined as symptoms ≥6 weeks) 2, 3
• Presence of pus or abscess which mandates drainage rather than antibiotics alone 1, 3
• Predisposing factors including ingrown toenail, occupational exposures, or medication-induced (especially EGFR inhibitors) 1, 4

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

• Implement warm water soaks for 15 minutes 3-4 times daily as first-line therapy 1, 2
• Alternative: white vinegar soaks (1:1 white vinegar:water dilution) for 15 minutes daily 5, 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 4
• Use mid-to-high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Oral antibiotics are NOT indicated at this stage unless adequate drainage cannot be achieved 2, 3

Grade 2 (Moderate) Paronychia

• Start oral antibiotics only if clear signs of infection are present 1, 2
• Preferred antibiotic agents: cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) 2
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 5, 1
• Consider potassium permanganate prophylactic soaks for antiseptic benefit 5, 4
• Refer to dermatology or podiatry if no improvement after 2 weeks 1, 2

Grade 3 (Severe) Paronychia

• Swab any pus for culture and prescribe antibiotics based on culture results and local resistance patterns 1, 2, 3
• Surgical drainage is mandatory if abscess is present; options range from hypodermic needle instrumentation to wide incision with scalpel 1, 3
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics 5, 1
• Apply silver nitrate weekly (by healthcare professional only) if over-granulation tissue has developed 5, 4
• Consider partial nail avulsion for recalcitrant cases or those associated with ingrown toenail 1, 6

Special Considerations for Chronic Paronychia

Chronic paronychia represents an irritant contact dermatitis rather than primarily infectious process, requiring a different treatment approach:

• Apply high-potency topical corticosteroids which have been found more effective than antifungals in chronic cases 1, 2
• Consider intralesional triamcinolone acetonide for recalcitrant cases 1
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in some cases 4
• Regular application of emollients to cuticles and periungual tissues is essential 1, 2
• Identify and eliminate irritant exposures (acids, alkalis, chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, swimmers) 3
• Note: Treatment may take weeks to months; patient education is paramount 3

Prevention of Recurrence

• Keep hands and feet as dry as possible; avoid prolonged soaking in water without adequate protection 1, 2
• Trim nails straight across and not too short to avoid nail trauma 1, 2, 4
• Moisturize regularly with emollients applied to cuticles and periungual tissues 1, 2, 4
• Wear protective gloves during wet work or exposure to irritants 1, 4
• Wear comfortable, well-fitting shoes that protect nails without being restrictive 5, 1, 4

Follow-up Protocol

• Reassess after 2 weeks of treatment for mild-to-moderate cases 1, 2
• If no improvement is seen, consider referral to dermatology or podiatry for further evaluation 1, 2
• For chronic cases, follow-up may extend to 8 weeks or longer given the prolonged treatment course 3, 7

Common Pitfalls to Avoid

• Don't overlook secondary bacterial or mycological superinfections, which are present in up to 25% of cases 1
• Don't prescribe systemic antibiotics routinely for paronychia associated with ingrown toenails unless infection is proven 8
• Don't use nail fold incisions for drainage; an intra-sulcal approach is preferable 6
• Don't assume all chronic paronychia is infectious; it is frequently a contact dermatitis with secondary colonization 3, 6
• Don't forget to investigate unusual causes (malignancy) in patients with chronic paronychia unresponsive to standard treatment 6