What is the treatment for paronychia?

Treatment of Paronychia

For acute paronychia, start with warm water or white vinegar soaks (1:1 dilution) for 15 minutes 3-4 times daily, combined with topical 2% povidone-iodine twice daily and mid-to-high potency topical corticosteroid ointment to the nail folds twice daily. 1, 2, 3

Initial Assessment

Evaluate severity based on four key parameters: 1, 2

• Redness and edema of the periungual tissue 1
• Presence of discharge or purulent material 1
• Granulation tissue formation 1
• Abscess formation, which mandates immediate drainage rather than conservative management alone 1, 2

Check for predisposing factors including ingrown toenail (onychocryptosis), occupational exposures to irritants, or medication-induced causes (particularly EGFR inhibitors or taxane chemotherapy). 1, 2

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

Conservative management is first-line: 1, 2, 3

• Antiseptic soaks with dilute white vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes 3-4 times daily 1, 3
• Topical 2% povidone-iodine applied twice daily to affected area 1, 2, 3
• Mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2, 3
• Daily application of emollients to cuticles and periungual tissues 4, 1

Grade 2 (Moderate) Paronychia

Add oral antibiotics if signs of infection are present: 2, 3

• First-line oral antibiotics: cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) 2, 3
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 2, 3
• Avoid clindamycin as it lacks adequate coverage for some streptococcal species and has increasing resistance patterns 3
• Continue topical very potent corticosteroids combined with topical antibiotics 2
• Be aware that up to 25% of cases have secondary bacterial or mycological superinfections 4, 1, 3

Grade 3 (Severe) Paronychia

Surgical drainage is required: 2

• Swab any pus for culture before starting antibiotics 2, 3
• Perform surgical drainage of abscess 2
• Prescribe appropriate antibiotics based on culture results and local resistance patterns 2, 3
• Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 3, 5

Chronic Paronychia Management

High-potency topical corticosteroids are more effective than antifungals and should be first-line treatment for chronic paronychia. 2

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 4, 2
• Regular application of emollients to cuticles and periungual tissues 4, 2
• Identify and eliminate irritants (acids, alkalis, chemicals, excessive moisture) 2, 5
• Treatment may take weeks to months 5

Special Situations

Paronychia with Pyogenic Granuloma

• Silver nitrate chemical cauterization for excessive granulation tissue 4, 1
• Scoop shave removal with hyfrecation or silver nitrate application 1
• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in patients with EGFR inhibitor-induced paronychia 4, 1
• Cryotherapy can also be considered 4

Paronychia with Ingrown Toenail

• Dental floss nail technique to separate the lateral nail edge from underlying tissue 1
• For intolerable grade 2 or grade 3 paronychia with onychocryptosis, surgical treatment with partial nail plate removal may be necessary 4

Recurrent or Treatment-Refractory Cases

• Consider intralesional triamcinolone acetonide 1
• Referral to dermatology or podiatry for further evaluation 1, 2, 3

Prevention of Recurrence

Patient education is paramount to reduce recurrence: 1, 2, 5

• Trim nails straight across and not too short 4, 1
• Avoid biting nails or cutting cuticles 4
• Avoid repeated friction, trauma, and excessive pressure 4, 1
• Wear protective gloves during activities involving water or chemicals 1, 2
• Wear comfortable well-fitting shoes and cotton socks 4, 1, 2
• Keep hands and feet dry 2
• Moisturize hands and feet regularly 2

Follow-up Protocol

• Reassess after 2 weeks of treatment 1, 2, 3
• If no improvement is seen, refer to dermatology or podiatry for further evaluation 1, 2, 3
• Obtain bacterial cultures in severe cases or treatment failures before starting antibiotics 3

Common Pitfalls to Avoid

• Do not use systemic antibiotics routinely for chronic paronychia or ingrown toenails unless infection is proven 6
• Do not rely on clindamycin as first-line therapy due to inadequate streptococcal coverage 3
• Do not delay drainage when an abscess is present—conservative management alone will fail 1, 2
• Do not overlook medication-induced causes, particularly in patients on EGFR inhibitors or taxane chemotherapy 4