What is the treatment for paronychia?

Treatment of Paronychia

For acute paronychia, initiate conservative management with warm water or dilute vinegar soaks (1:1 dilution) for 15 minutes 3-4 times daily, combined with topical 2% povidone-iodine twice daily and mid-to-high potency topical corticosteroid ointment to the nail folds twice daily. 1, 2

Initial Assessment

• Determine if acute versus chronic: Acute presents with sudden onset pain, erythema, and swelling; chronic persists ≥6 weeks and represents an irritant dermatitis 3, 4
• Assess for abscess formation: Look for fluctuance or visible pus collection, which mandates drainage 1, 2
• Evaluate severity: Grade based on redness, edema, discharge, and granulation tissue presence 1
• Check for secondary infection: Up to 25% have bacterial or fungal superinfection involving both gram-positive and gram-negative organisms 5, 2

Conservative Management (First-Line for Mild-Moderate Cases)

Topical Therapy

• 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
• For chronic paronychia specifically: High-potency topical corticosteroids have proven more effective than antifungals and should be the mainstay 5, 4

Antiseptic Soaks

• Warm water soaks for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 dilution) for 15 minutes daily 2
• Alternative: Dilute vinegar (50:50 dilution) or povidone-iodine soaks for 10-15 minutes twice daily 1

Adjunctive Measures

• Daily application of emollients to cuticles and periungual tissues 5, 1

Antimicrobial Therapy

When to Add Oral Antibiotics

• Start oral antibiotics if signs of infection are present (increased warmth, purulence, spreading erythema) 2
• First-line agents: Cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) 2
• If cephalexin fails: Switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1, 2
• Avoid clindamycin: Lacks adequate streptococcal coverage and has increasing resistance patterns 2

Culture Guidance

• Obtain bacterial cultures before starting antibiotics in severe cases or treatment failures 2
• Swab any pus for culture and adjust antibiotics based on results 2

Important caveat: Oral antibiotics are usually unnecessary if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 2, 3

Surgical Interventions

Indications for Drainage

• Any abscess formation mandates drainage 1, 2
• Intolerable grade 2 or grade 3 paronychia requires surgical intervention 5, 2

Drainage Techniques

• Simple needle instrumentation: Use 21G or 23G needle to lift the nail fold and drain pus—no anesthesia required 6
• Incision and drainage: Wide incision with scalpel for larger abscesses 2, 3
• Partial nail plate avulsion: For severe cases with pyogenic granuloma or onychocryptosis 5, 2

Management of Granulation Tissue

• Silver nitrate chemical cauterization for excessive granulation tissue 5, 1
• Cryotherapy as alternative option 5
• Scoop shave removal with hyfrecation for pyogenic granuloma 1

Special Considerations

Refractory Cases

• Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance of periungual pyogenic granulomas 5, 1, 2
• Intralesional triamcinolone acetonide for recurrent or treatment-refractory cases 1

Chronic Paronychia Management

• Identify and eliminate irritant exposure: Common culprits include acids, alkalis, chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, and swimmers 3, 4
• High-potency topical corticosteroids or calcineurin inhibitors are more effective than antifungals 3, 4
• Treatment may take weeks to months 3

Candidal Paronychia

• Drainage is the most important intervention 2
• Topical azoles or polyenes are effective 2
• Keep infected area dry 2

Prevention Education

Critical preventive measures to discuss with all patients: 5, 1, 2

• Avoid biting nails or cutting nails too short
• Trim nails straight across, not too short
• Daily emollient application to cuticles and periungual tissues
• Wear gloves during water exposure or chemical handling
• Wear comfortable, well-fitting shoes and cotton socks
• Avoid repeated friction, trauma, and excessive pressure

Follow-Up Protocol

• Reassess after 2 weeks of treatment 1, 2, 7
• If no improvement or worsening: Escalate therapy or consider specialist referral 1, 2
• Refer to dermatology or podiatry (not general surgery) for treatment-refractory cases 7
• Hand surgery consultation only for severe finger paronychia requiring advanced surgical intervention 7

Common Pitfalls to Avoid

• Do not reflexively prescribe systemic antibiotics for paronychia without proven infection—they are ineffective for ingrown nails and irritant dermatitis 8
• Do not refer to general surgery—dermatology and podiatry are the appropriate specialties 7
• Do not use antifungals as first-line for chronic paronychia—topical steroids are more effective 4
• Do not overlook the 25% rate of secondary superinfection—consider cultures in non-responding cases 5, 2