What antibiotic is used to treat an infected hangnail?

Antibiotic Treatment for Infected Hangnail (Acute Paronychia)

For a mild to moderate infected hangnail, use oral trimethoprim-sulfamethoxazole or amoxicillin-clavulanate as first-line antibiotics; for penicillin-allergic patients, use clindamycin, cefalexin, or dicloxacillin. 1

Initial Assessment and Severity Classification

Determine infection severity before selecting antibiotics:

• Mild infection: Local inflammation, pain, and minimal discharge around the nail fold 1
• Moderate infection: More extensive inflammation, purulent discharge, and pain limiting instrumental activities of daily living 1
• Severe infection: Significant inflammation extending beyond the toe/finger, systemic symptoms, or limiting self-care activities 1

The most common pathogen is Staphylococcus aureus, though polymicrobial infections including gram-negative organisms can occur 1, 2

First-Line Antibiotic Selection

For Mild to Moderate Infections:

• Trimethoprim-sulfamethoxazole or amoxicillin-clavulanate are recommended as first-line oral antibiotics 1
• Alternative first-line options include cefalexin (cephalexin) or dicloxacillin, which provide appropriate coverage for gram-positive cocci 1

For Penicillin-Allergic Patients:

• Clindamycin is the appropriate choice 1, 3
• Doxycycline is an alternative option providing coverage for gram-positive cocci 1

Treatment Duration

• Mild infections: 1-2 weeks of antibiotic treatment 1
• Moderate infections: 2-4 weeks of antibiotic treatment 1

Concurrent Topical Measures

Always combine antibiotics with topical antimicrobial measures to enhance treatment outcomes:

• Povidone-iodine 2% soaks 1
• Dilute vinegar soaks (50:50 dilution) twice daily 1
• Topical antibiotics with corticosteroids for inflammation 1
• Warm water soaks with or without Burow solution or 1% acetic acid 2

When to Consider MRSA Coverage

Add MRSA-directed therapy if the patient has:

• Prior MRSA infection 1
• Recent antibiotic exposure 1
• Failure of initial beta-lactam therapy 1

For suspected MRSA, add trimethoprim-sulfamethoxazole, clindamycin, or linezolid to the regimen 1

Severe Infections Requiring IV Therapy

For severe infections with systemic symptoms:

• Piperacillin-tazobactam IV 1
• Levofloxacin or ciprofloxacin with clindamycin IV 1
• Vancomycin 30 mg/kg/day in 2 divided doses IV if MRSA is suspected 1

Critical Management Points

Abscess Drainage:

• If an abscess is present, drainage is mandatory and takes priority over antibiotics alone 2
• Various drainage techniques range from instrumentation with a hypodermic needle to wide incision with a scalpel 2

Antibiotic Stewardship:

• Avoid broad-spectrum empirical therapy for mild infections—therapy aimed at aerobic gram-positive cocci is sufficient for mild-to-moderate infections in patients without recent antibiotic exposure 1
• Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or has severe infection 2

Monitoring Response:

• Monitor clinical response within 2-5 days for outpatients 1
• Consider changing antibiotics based on culture results or surgical intervention if no improvement is seen 1

Common Pitfalls to Avoid

• Do not use systemic antibiotics routinely for simple paronychia without proven infection 4
• Do not confuse herpetic whitlow (viral) with bacterial paronychia—herpetic whitlow may mimic an abscess but requires non-operative treatment, whereas bacterial abscess requires drainage 5, 6
• Do not overlook chronic paronychia, which is often an irritant dermatitis rather than infection and requires topical steroids or calcineurin inhibitors, not antibiotics 2