Treatment of Paronychia (Infection Next to Nail Bed)
For acute paronychia, begin with warm water soaks 10-15 minutes, 2-3 times daily, combined with mid-to-high potency topical corticosteroid ointment to the nail folds twice daily. 1
Acute Paronychia Treatment Algorithm
First-Line Conservative Management
- Warm water soaks for 10-15 minutes, 2-3 times daily are the cornerstone of initial treatment 1
- Alternatively, use dilute vinegar soaks (50:50 dilution with water) twice daily instead of warm water 1
- Apply mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1
- Keep the affected area clean and dry between soaks 2
When Abscess is Present
- Surgical drainage is mandatory before antibiotic therapy if an abscess has formed 1, 2
- Use an intra-sulcal approach rather than a nail fold incision for drainage 3
- Obtain culture of purulent material to guide antibiotic therapy 1
Antibiotic Therapy Indications
- Reserve antibiotics for cases with proven bacterial infection or when abscess is present 4
- Cephalexin is the recommended first-line antibiotic, particularly effective against Staphylococcus aureus and Streptococcus pyogenes 2
- For recurrent, severe, or treatment-refractory cases, consider doxycycline 100 mg twice daily with follow-up after 1 month 1
- Both gram-positive and gram-negative organisms can be implicated 1
Special Considerations
- Do not use systemic antibiotics routinely unless infection is proven, as paronychia is often inflammatory rather than infectious 4
- If associated with ingrown nail (onychocryptosis), use dental floss nail splinting, cotton packing, or cast edge separation 1
- For recurrent or severe cases, consider intralesional triamcinolone acetonide 1
Chronic Paronychia (Symptoms ≥6 Weeks)
Chronic paronychia represents an irritant contact dermatitis rather than a primarily infectious process and requires a different approach 1
- Most commonly affects individuals with wet occupations (housekeepers, dishwashers, bartenders, florists, bakers, swimmers) 1
- Up to 25% have secondary bacterial or mycological superinfection that requires treatment 1
- Chronic moisture exposure causes cuticle detachment, allowing microorganisms to enter and cause inflammation in the nail matrix area 5
Treatment Approach for Chronic Paronychia
- Address the underlying contact dermatitis with topical corticosteroids 1
- Treat any secondary fungal colonization (commonly Candida parapsilosis or Candida guilliermondii) with appropriate antifungals 6
- Consider dermatology consultation for chronic cases unresponsive to standard treatment 3
Critical Prevention Measures to Prevent Recurrence
Patient education is paramount to prevent recurrence 1:
- Avoid excessive moisture exposure and wear protective gloves when working with chemicals 1, 7
- Apply daily topical emollients to cuticles and periungual tissues 1, 7
- Avoid nail-biting, finger-sucking, or cutting nails too short 1
- Trim nails regularly, ensuring they are straight and not too short 1
- Wear comfortable well-fitting shoes and cotton socks for toenail paronychia 1
- Practice gentle skin care and avoid repeated friction/trauma 1
Common Pitfalls to Avoid
- Do not prescribe antibiotics empirically without evidence of bacterial infection, as most acute paronychia responds to conservative measures alone 4
- Do not confuse with onychomycosis, which is a chronic fungal infection requiring weeks to months to develop, presenting with nail thickening, discoloration, and friable texture—not acute swelling 1
- Do not miss chronic paronychia in patients with wet occupations, as this requires addressing the underlying contact dermatitis rather than repeated antibiotic courses 5, 1
- Investigate for malignancy in patients with chronic paronychia unresponsive to standard treatment 3