How to manage paronychia?

Management of Paronychia

For acute paronychia, initiate treatment with antiseptic soaks (warm water or 1:1 white vinegar solution for 15 minutes 3-4 times daily), topical 2% povidone-iodine twice daily, and mid-to-high potency topical corticosteroid ointment to the nail folds twice daily; if an abscess is present, drainage is mandatory before considering antibiotics. 1, 2

Initial Assessment

Evaluate severity based on these specific parameters 1, 3:

• Degree of erythema and edema 1
• Presence of purulent discharge 1
• Granulation tissue formation 1
• Abscess formation requiring drainage 1, 2

Identify predisposing factors including ingrown toenail (onychocryptosis), occupational water/chemical exposure, or medication-induced causes (particularly EGFR tyrosine kinase inhibitors) 1, 3

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

Conservative management is first-line 1, 2:

• Implement warm water soaks for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 dilution with water) for 15 minutes daily 1, 2
• Apply topical 2% povidone-iodine twice daily to affected area 1, 2
• Use mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Continue current activities without restriction 4

Critical pitfall: Grade 1 can escalate to Grade 2 very quickly, so patients must contact their healthcare provider immediately if symptoms worsen 4

Grade 2 (Moderate) Paronychia

Escalate to oral antibiotics if conservative measures fail after 2 weeks 1, 2, 3:

• First-line oral antibiotic: 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

Continue topical therapy with very potent corticosteroids combined with topical antibiotics/antifungals 4, 3

Apply silver nitrate weekly (by healthcare provider only) if over-granulation tissue develops 4, 3

For toenail involvement, consult podiatry 4

Grade 3 (Severe) Paronychia

Surgical drainage is mandatory for any abscess formation 1, 2, 3:

• Swab purulent material for bacterial/fungal culture before starting antibiotics 2, 3
• Drainage options range from hypodermic needle instrumentation to wide scalpel incision 2, 5
• Partial nail plate avulsion may be necessary for severe cases with pyogenic granuloma 2

Oral antibiotics are indicated after drainage if patient is immunocompromised or severe infection is present 2, 5

For medication-induced paronychia (EGFR-TKIs), discontinue the causative agent and only reinstate when resolved to Grade 2 4

Chronic Paronychia Management

High-potency topical corticosteroids are more effective than antifungals and should be first-line treatment 3, 6:

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics twice daily 1, 3
• Regular application of emollients to cuticles and periungual tissues 1, 3
• Identify and eliminate irritants (acids, alkalis, chemicals from occupational exposure) 3, 5

Important consideration: Up to 25% of paronychia cases have secondary bacterial or mycological superinfections, so obtain cultures if treatment fails 1, 2, 3

Special Interventions for Refractory Cases

For pyogenic granuloma formation 1, 2:

• Silver nitrate chemical cauterization 1, 2
• Scoop shave removal with hyfrecation 1
• Topical timolol 0.5% gel twice daily under occlusion for 1 month 1, 2

For ingrown toenail with paronychia, use dental floss nail technique to separate lateral nail edge from underlying tissue 1

Consider intralesional triamcinolone acetonide for recurrent, severe, or treatment-refractory cases 1

Prevention of Recurrence

Patient education is paramount to prevent recurrence 3, 5:

• Keep hands and feet dry; avoid prolonged soaking in soapy water without protection 4, 3
• Trim nails straight across, not too short 1, 3
• Avoid nail trauma, biting nails, or cutting cuticles 2, 3
• Apply emollients daily to cuticles and periungual tissues 1, 2
• Wear protective gloves during water/chemical exposure 1, 3
• Wear comfortable, well-fitting shoes and cotton socks for toenail paronychia 1, 3
• Dry feet carefully before putting on shoes 4

Follow-up Protocol

Reassess after 2 weeks of treatment 1, 2, 3:

• If no improvement, escalate therapy to next level 2
• Consider referral to dermatology or podiatry if no improvement after appropriate treatment 1, 2, 3
• For chronic paronychia, treatment may take weeks to months 5, 6