What is the treatment for paronychia?

Treatment of Paronychia

For acute paronychia, initiate warm water soaks 3-4 times daily combined with topical povidone-iodine 2% twice daily, reserving oral antibiotics (cephalexin or amoxicillin-clavulanate) for cases with signs of infection, and perform drainage if an abscess is present. 1

Initial Conservative Management

Mild cases (Grade 1):

• Implement warm water soaks for 15 minutes 3-4 times daily, or alternatively use white vinegar soaks (1:1 dilution) for 15 minutes daily 1
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 2
• Use mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Topical antibiotics combined with corticosteroids can be added if simple soaks do not relieve inflammation 3

Important caveat: Avoid topical steroids if purulent drainage is present 2

Antibiotic Therapy

When to use oral antibiotics:

• Reserve for cases with localized cellulitis, purulent drainage, significant erythema, or signs of spreading infection 1, 2
• Oral antibiotics are usually unnecessary if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 1, 3

Antibiotic selection for standard acute paronychia:

• First-line: Cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) 1, 2
• If cephalexin fails or MRSA suspected: Sulfamethoxazole-trimethoprim (Bactrim) provides broader coverage including MRSA 1, 2
• Avoid clindamycin: Inadequate coverage for some streptococcal species and increasing resistance patterns make it suboptimal 1, 2

For drug-induced paronychia (chemotherapy/EGFR inhibitors):

• Doxycycline or minocycline are specifically recommended due to anti-inflammatory properties beyond antimicrobial effects 2

Surgical Management

Indications for drainage:

• Any abscess formation mandates drainage 3, 4
• Intolerable grade 2 or grade 3 paronychia requires surgical intervention 5

Drainage techniques:

• Options range from instrumentation with a hypodermic needle to wide incision with scalpel 3
• For severe cases with pyogenic granuloma, partial nail plate avulsion may be necessary 5

Special Considerations

Microbiological assessment:

• Up to 25% of paronychia cases have secondary bacterial or mycological superinfections 1, 2
• Obtain bacterial/viral/fungal cultures before starting antibiotics, especially in severe cases or treatment failures 5, 1, 2
• Both gram-positive and gram-negative organisms have been implicated 5

For candidal paronychia:

• The most important intervention is drainage 5
• Topical azoles (clotrimazole, miconazole) and polyenes (nystatin) are effective for candidal skin infections 5
• Keep the infected area dry 5

Advanced Therapies for Refractory Cases

For persistent pyogenic granuloma:

• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in patients with periungual pyogenic granulomas 5
• Silver nitrate chemical cauterization can be considered 5
• Cryotherapy is an alternative option 5

Follow-Up Protocol

• Reassess after 2 weeks of treatment (either by healthcare professional or patient self-report) 5, 1, 2
• If reactions worsen or do not improve, escalate therapy to the next level 5
• Consider referral to dermatology or podiatry if no improvement is seen after appropriate treatment 1

Prevention Education

Critical preventive measures to discuss with patients:

• Avoid biting nails or cutting nails too short 5
• Regular trimming ensuring nails are straight and not too short 5
• Daily application of topical emollients to cuticles and periungual tissues 5
• Wear gloves while cleaning and avoid repeated friction/trauma 5
• Wear comfortable well-fitting shoes and cotton socks 5
• Use antimicrobial soaks and washing with cleansers 5

Common pitfall: Systemic antibiotics are frequently overused in paronychia when adequate drainage and local care would suffice, particularly in cases associated with ingrown nails where infection is not proven 6, 7