What oral medication is recommended for treating paronychia?

Oral Medication for Paronychia

For acute bacterial paronychia requiring oral antibiotics, cephalexin or amoxicillin-clavulanate are first-line choices, while doxycycline or minocycline are specifically recommended for drug-induced paronychia due to their anti-inflammatory properties. 1

When Oral Antibiotics Are Actually Needed

Most cases of paronychia do not require oral antibiotics if adequate drainage is achieved. 2 Oral antibiotics are indicated when:

• Moderate-to-severe infection is present with significant surrounding cellulitis 1
• The patient is immunocompromised 2
• Adequate drainage cannot be achieved 2
• Treatment failure occurs after topical therapy and drainage 3

A critical pitfall: systemic antibiotics should not be used routinely, as up to 25% of paronychia cases involve secondary bacterial or fungal superinfections that require culture-directed therapy. 3, 4

Antibiotic Selection Algorithm

For Standard Acute Bacterial Paronychia:

• First-line: Cephalexin (e.g., 500 mg four times daily) or amoxicillin-clavulanate 1
• Avoid: Clindamycin due to inadequate streptococcal coverage and increasing resistance 1
• Culture-directed therapy: If no response after 2 weeks, obtain bacterial, viral, and fungal cultures and switch to broader spectrum coverage based on results 3

For Drug-Induced Paronychia (EGFR inhibitors, chemotherapy):

• Preferred: Doxycycline or minocycline specifically for their anti-inflammatory effects beyond antimicrobial activity 1
• Alternative empirical options: Oral cephalosporins, ciprofloxacin, levofloxacin, or moxifloxacin based on microbiological analysis showing high activity against common pathogens (72% Gram-positive, 23% Gram-negative bacteria) 5

For Candida-Associated Chronic Paronychia:

• First-line: Topical imidazole lotions 4
• For nail plate invasion: Oral itraconazole 200 mg daily or pulse therapy 400 mg daily for 1 week per month, repeated for 2-4 months 4
• Avoid: Terbinafine, which has limited and unpredictable activity against Candida 4

Treatment Failure Management

If paronychia does not respond to initial cephalexin therapy:

1. Obtain cultures immediately for bacterial, viral, and fungal organisms to identify resistant pathogens 3
2. Switch antibiotic class based on culture results; if cultures pending, consider broader spectrum coverage 3
3. Reassess after 2 weeks of new regimen; if no improvement, refer to dermatology or hand surgery 3

Essential Concurrent Measures

Oral antibiotics alone are insufficient. Always combine with:

• Topical povidone-iodine 2% twice daily 3, 4
• Antiseptic soaks with dilute vinegar (50:50 dilution) for 10-15 minutes twice daily 3, 2
• Drainage if abscess present—this is mandatory and the most important intervention 4
• High-potency topical corticosteroids to reduce inflammation (except when purulent drainage present) 3, 1

Critical Caveats

• Do not prescribe oral antibiotics reflexively—they are ineffective for ingrown toenails unless proven infection exists 6
• Chronic paronychia is primarily irritant contact dermatitis, not infection; oral antibiotics are inappropriate and topical steroids or calcineurin inhibitors are indicated instead 2, 6
• Treatment duration: Chronic cases may require weeks to months of therapy 2
• Prevention is paramount: Keep hands dry, avoid nail trauma, wear protective gloves, trim nails straight across, and apply emollients regularly 3, 4