What is the treatment for paronychia?

Treatment of Paronychia

For acute paronychia, start with warm water or dilute vinegar soaks (1:1 white vinegar:water) for 15 minutes 3-4 times daily combined with topical 2% povidone-iodine twice daily, reserving antibiotics only for cases with significant infection or abscess formation. 1, 2

Initial Assessment

Determine whether the paronychia is acute or chronic based on duration (chronic is ≥6 weeks of symptoms) and evaluate severity by examining for:

• Degree of redness, edema, and discharge 1, 2
• Presence of pus or abscess requiring drainage 1, 2
• Associated ingrown toenail (onychocryptosis) 1, 2
• Secondary bacterial or fungal superinfection, which occurs in up to 25% of cases 1, 3

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

• Implement antiseptic soaks as first-line therapy: warm water for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 dilution) for 15 minutes daily 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 2
• Use mid to high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Topical antibiotics are not routinely needed unless signs of bacterial infection are present 4, 5

Grade 2 (Moderate) Paronychia

• Continue antiseptic soaks and topical povidone-iodine 1, 2
• Apply very potent topical corticosteroids, preferably combined with topical antibiotics and/or antiseptics 1
• Start oral antibiotics only if clear signs of infection are present (increased warmth, purulent discharge, spreading erythema) 1, 5
• If abscess is present, drainage is mandatory before antibiotics will be effective 1, 2, 5

Grade 3 (Severe) Paronychia

• Obtain culture of any purulent drainage to guide antibiotic selection 3
• Perform surgical drainage using techniques ranging from needle instrumentation to incision with scalpel 5, 6
• Prescribe appropriate oral antibiotics based on culture results and local resistance patterns 3, 5
• Consider partial nail avulsion for intolerable symptoms or pyogenic granuloma formation 4, 3
• Silver nitrate chemical cauterization can be used for excessive granulation tissue 4, 2

Chronic Paronychia Management

High-potency topical corticosteroids are more effective than antifungals for chronic paronychia, as this condition represents an irritant dermatitis rather than primarily an infectious process 1, 7

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 4, 2
• Consider topical calcineurin inhibitors as an alternative anti-inflammatory agent 5
• For recalcitrant cases, intralesional triamcinolone acetonide may be beneficial 1, 2
• Topical timolol 0.5% gel twice daily under occlusion has shown complete clearance in some cases 4, 2
• Treatment may require weeks to months for resolution 5, 7

Antibiotic Selection

When oral antibiotics are indicated:

• Base selection on likely pathogens (Staphylococcus aureus, Streptococcus) and local resistance patterns 5, 8
• If initial therapy with cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 3
• Oral antibiotics are usually unnecessary if adequate drainage is achieved, unless the patient is immunocompromised 5

Prevention of Recurrence

Patient education is paramount to prevent recurrence 5:

• Keep hands and feet dry; avoid prolonged water exposure 1, 2, 3
• Trim nails straight across and not too short 4, 2, 3
• Apply emollients daily to cuticles and periungual tissues 4, 1, 2
• Wear protective gloves during wet work or chemical exposure 1, 2, 3
• Wear comfortable, well-fitting shoes and cotton socks 4, 2
• Avoid nail biting, trauma, and cutting cuticles 4, 1

Follow-Up and Monitoring

• Reassess after 2 weeks of treatment 1, 2, 3
• If no improvement occurs, consider referral to dermatology or podiatry for further evaluation 1, 2, 3
• Monitor for development of pyogenic granuloma, which may require scoop shave removal with hyfrecation or silver nitrate application 2

Common Pitfalls to Avoid

• Do not prescribe systemic antibiotics routinely without evidence of infection or adequate drainage 5, 8
• Do not overlook secondary bacterial or fungal superinfections, present in up to 25% of cases 1, 3
• For chronic paronychia, recognize this is primarily an inflammatory condition, not an infection—topical steroids are more effective than antifungals 1, 7
• Do not ignore predisposing factors like ingrown toenails or occupational irritant exposure, which must be addressed for successful treatment 2, 3, 7