First-Line Antibiotic for Nail Fold Infection and Wound Care
For acute bacterial paronychia (nail fold infection), cephalexin 500mg four times daily for 7-10 days is the first-line antibiotic choice, combined with topical antiseptic measures including povidone-iodine 2% soaks twice daily. 1
Antibiotic Selection Based on Infection Severity
Mild Infections (Grade 1)
- Topical therapy alone may suffice: topical povidone-iodine 2% with topical antibiotics/corticosteroids 2
- Reassess after 2 weeks; if no improvement, escalate to oral antibiotics 2
Moderate Infections (Grade 2)
First-line oral antibiotics:
- Cephalexin 500mg four times daily for 7-10 days (preferred for gram-positive coverage including Staphylococcus aureus and Streptococcus species) 1
- Amoxicillin-clavulanate 875/125mg twice daily for 7-10 days (provides additional anaerobic and beta-lactamase coverage) 1, 3
- Dicloxacillin is an alternative first-line option 2, 3
For penicillin allergy:
If MRSA suspected (prior MRSA infection, recent antibiotic failure, or no improvement after 48-72 hours):
Severe Infections (Grade 3)
- Interrupt causative agent if drug-induced 2
- Obtain bacterial/viral/fungal cultures 2
- Continue oral antibiotics or consider surgical intervention (partial nail avulsion) 2
- If systemic signs present, consider IV therapy with vancomycin 30mg/kg/day in 2 divided doses for MRSA coverage 3
Essential Wound Care Measures
Topical Antiseptic Protocol
- Povidone-iodine 2% soaks twice daily (cornerstone of local therapy) 2, 1
- Dilute vinegar soaks (50:50 dilution) twice daily as alternative antiseptic measure 2, 1, 3
- Apply topical antibiotics with corticosteroids to reduce inflammation 2, 1
Mechanical Interventions
- Tape nail fold away from nail plate to relieve pressure 2
- For onychocryptosis (ingrown nail component): dental floss nail splinting or cotton packing under lateral nail edge 2
- Avoid cutting nails too short; wear comfortable shoes to prevent trauma 2
Granulation Tissue Management
- Silver nitrate application for excessive granulation tissue 2, 1
- Scoop shave removal with hyfrecation for recurrent or severe granulation tissue 2
- High-potency topical steroids or intralesional triamcinolone acetonide for refractory cases 2
Critical Microbiological Considerations
The microbiology of acute paronychia is typically polymicrobial (73% of cases), with the most common pathogens being:
- Enterococcus faecalis (14%)
- Staphylococcus aureus (12%)
- Candida albicans (9%)
- Enterobacter cloacae (8%)
- Klebsiella pneumoniae (7%) 4
This polymicrobial nature explains why broad-spectrum coverage with amoxicillin-clavulanate may be superior to narrow-spectrum agents in moderate infections, though cephalexin remains first-line for uncomplicated cases 1, 4.
Treatment Duration and Monitoring
- Standard duration: 7-10 days for mild-moderate infections 1
- Re-evaluate after 2-3 days to ensure clinical improvement 1
- If no improvement after 48-72 hours, consider MRSA coverage or surgical intervention 1
- Cultures are not routinely needed for typical cases but should be obtained in diabetic, immunocompromised, or recurrent infections 1, 3
Common Pitfalls to Avoid
- Do not use broad-spectrum empirical therapy for mild infections—narrow-spectrum agents targeting gram-positive cocci are sufficient and promote antibiotic stewardship 3
- Do not close contaminated wounds with sutures—this increases infection risk; use sterile dressing only 5
- Do not ignore the need for mechanical relief—antibiotics alone without addressing nail fold pressure or ingrown nail components will lead to treatment failure 2
- Avoid topical steroids if active purulent infection is present until infection is controlled with antibiotics 2
Special Populations
Diabetic Patients
- Require more aggressive treatment and closer follow-up 1
- Consider broader spectrum antibiotics (amoxicillin-clavulanate or fluoroquinolones) for moderate-severe infections 2, 1