What is the first-line treatment for nail fold infection (paronychia)?

First-Line Treatment for Nail Fold Infection (Paronychia)

For mild acute paronychia, warm water soaks combined with topical povidone-iodine 2% is the recommended first-line treatment, with no oral antibiotics needed. 1

Initial Management Approach

Mild Paronychia (No Abscess)

• Warm water soaks remain the cornerstone of initial therapy, with or without Burow solution or 1% acetic acid added to enhance antimicrobial activity 2
• Topical povidone-iodine 2% should be applied to the affected nail fold as specifically recommended by the American Academy of Dermatology 1
• Topical antibiotics combined with topical corticosteroids can be added if simple soaks do not adequately control inflammation within the first few days 1, 2
• Oral antibiotics are not indicated for mild cases when adequate local treatment is provided 1

Moderate Paronychia (Increased Erythema/Swelling)

• Oral antibiotics become necessary when local measures fail or infection severity increases 1
• Amoxicillin-clavulanate 500/125 mg every 12 hours is the preferred oral antibiotic for standard acute bacterial paronychia 3
• Cephalexin represents an alternative first-line oral option if amoxicillin-clavulanate is not tolerated 1
• Doxycycline 100 mg twice daily should be chosen specifically for drug-induced paronychia (from chemotherapy or targeted therapies) due to its anti-inflammatory properties beyond antimicrobial effects 1, 3
• Continue topical povidone-iodine 2% alongside oral therapy 3

Severe Paronychia (Abscess Present)

• Surgical drainage is mandatory when an abscess has formed, as antibiotics alone will not adequately treat a walled-off collection 1, 2
• Drainage techniques range from simple instrumentation with a hypodermic needle to formal incision with scalpel, depending on abscess size 2
• Obtain bacterial cultures before starting antibiotics in severe cases or treatment failures, as up to 25% have bacterial or fungal superinfections 1
• Culture-directed antibiotic therapy should guide treatment after drainage 1
• Oral antibiotics are indicated post-drainage only if the patient is immunocompromised or severe infection extends beyond the immediate nail fold 2

Critical Clinical Considerations

Reassessment Timeline

• Mandatory reassessment after 2 weeks of treatment is required to determine response 1, 3
• If no improvement or worsening occurs after 2 weeks, escalate therapy or consider surgical intervention 1, 3

Common Pitfalls to Avoid

• Never use clindamycin due to inadequate coverage for some streptococcal species and increasing resistance patterns 1
• Avoid topical steroids when purulent drainage is present, as this can worsen bacterial infection 1
• Do not routinely prescribe systemic antibiotics for ingrown toenails with paronychia unless proven infection exists, as antibiotics are ineffective for mechanical inflammation alone 4

Special Populations

• For drug-induced paronychia from chemotherapy agents, doxycycline or minocycline are specifically preferred over standard antibiotics due to their anti-inflammatory mechanisms 1