What is the treatment for paronychia?

Treatment of Paronychia

For paronychia, start with warm water soaks 3-4 times daily combined with topical povidone-iodine 2% and mid-to-high potency topical steroids, reserving oral antibiotics only for moderate-to-severe infections with signs of systemic involvement. 1, 2

Initial Assessment

Evaluate severity by examining for:

• Redness, edema, and tenderness of the nail fold 1, 2
• Presence of pus or abscess formation requiring drainage 1, 2
• Duration of symptoms (acute vs chronic: symptoms ≥6 weeks indicate chronic paronychia) 3, 4
• Predisposing factors such as ingrown toenail or occupational exposures 1

Treatment Algorithm by Severity

Grade 1 (Mild) Paronychia

• Warm water soaks for 15 minutes 3-4 times daily OR white vinegar soaks (1:1 white vinegar:water dilution) for 15 minutes daily 1, 2
• Apply topical 2% povidone-iodine twice daily to the affected area 1, 5
• Use mid-to-high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1, 2
• No oral antibiotics needed at this stage 2, 3

Grade 2 (Moderate) Paronychia

• Continue warm water or white vinegar soaks 6, 1
• Apply topical very potent steroids, antifungals, antibiotics and/or antiseptics (preferably as combination preparations) 6, 1
• Start oral antibiotics if signs of infection are present: preferred agents include cephalexin or amoxicillin-clavulanate 500/125 mg every 12 hours 2
• Consider potassium permanganate prophylactic soaks 6
• Apply silver nitrate weekly by healthcare professional only if over-granulation has developed 6

Grade 3 (Severe) Paronychia

• Swab any pus for culture and prescribe appropriate antibiotics based on culture results 1, 2
• Continue topical very potent steroids, antifungals, antibiotics and/or antiseptics 6
• Apply silver nitrate if over-granulation present 6
• Consider surgical intervention for drainage or partial nail avulsion 1, 2, 3
• Drainage options range from instrumentation with a hypodermic needle to wide incision with scalpel 3

Chronic Paronychia (≥6 Weeks Duration)

High-potency topical corticosteroids are more effective than antifungals for chronic paronychia. 1, 4

• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 1, 2, 4
• Consider intralesional triamcinolone acetonide for recalcitrant cases 1
• Topical timolol 0.5% gel twice daily under occlusion has shown complete clearance in some cases 1, 5
• Address underlying irritant exposure (acids, alkalis, chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, swimmers) 3, 4
• Treatment may take weeks to months 3

Prevention of Recurrence

• Keep hands and feet as dry as possible; avoid prolonged soaking in water 1, 2, 5
• Avoid nail trauma/injury and cutting nails too short; trim nails straight across 1, 2, 5
• Apply emollients regularly to cuticles and periungual tissues 6, 1, 2
• Wear protective gloves during wet work or exposure to irritants 1, 2, 5
• Wear comfortable well-fitting shoes that protect nails without being restrictive 6, 1, 5

Follow-up Protocol

• Reassess after 2 weeks of treatment 1, 2
• If no improvement, refer to dermatology or podiatry for further evaluation 1, 2
• Consider referral to hand surgery for severe or recalcitrant cases 5

Common Pitfalls to Avoid

• Don't overlook potential secondary bacterial or mycological superinfections, present in up to 25% of cases 1
• Avoid systemic antibiotics unless adequate drainage cannot be achieved or patient is immunocompromised 2, 3
• Don't use systemic antibiotics for ingrown nail-associated paronychia unless infection is proven 7
• Patient education is paramount to reduce recurrence 3