What is the treatment for paronychia?

Treatment of Paronychia

For acute paronychia, start 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; if an abscess is present, immediate drainage is mandatory before any other treatment. 1, 2

Initial Assessment

Evaluate for the following critical features that determine treatment pathway:

• Check for abscess or pus formation - presence of fluctuance mandates immediate surgical drainage rather than antibiotics alone 1, 2
• Assess severity parameters including redness, edema, discharge, and granulation tissue 1
• Identify predisposing factors such as ingrown toenail (onychocryptosis) which requires specific management 1
• Obtain bacterial, viral, and fungal cultures before starting antimicrobials, as up to 25% of cases involve secondary bacterial or mycological superinfections 2, 3

First-Line Conservative Treatment (Mild Cases Without Abscess)

Topical Therapy

• Antiseptic soaks: Warm water for 15 minutes 3-4 times daily OR white vinegar soaks (50:50 dilution with water) for 10-15 minutes twice daily 1, 2
• Topical 2% povidone-iodine applied twice daily to the affected area 1, 2, 3
• Mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2, 3

This combination addresses both the infectious and inflammatory components simultaneously.

Antibiotic Therapy (Moderate to Severe Infection)

When to Use Oral Antibiotics

• Signs of spreading infection beyond the nail fold 2
• Immunocompromised patients 2
• Severe infection even after adequate drainage 2

Antibiotic Selection

• First-line: Cephalexin OR amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) 2
• If cephalexin fails or MRSA suspected: Switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1, 2, 3
• Avoid clindamycin - lacks adequate streptococcal coverage and has increasing resistance patterns 2

Important Caveat

Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 2

Surgical Drainage (Abscess Present)

Any abscess formation mandates drainage - this is non-negotiable 1, 2, 3

Drainage Options

• Simple instrumentation with hypodermic needle for small collections 2
• Wide incision with scalpel for larger abscesses 2
• Intra-sulcal approach is preferable to nail fold incision 4
• Partial nail plate avulsion may be necessary for severe cases with pyogenic granuloma or grade 3 paronychia 2, 3

Post-Drainage Management

• Swab any pus for culture and adjust antibiotics based on results 2
• Continue topical povidone-iodine and corticosteroids 3

Chronic Paronychia Management

Chronic paronychia (symptoms ≥6 weeks) represents an irritant dermatitis rather than primarily infectious process 5

• High-potency topical corticosteroids alone or combined with topical antibiotics 1
• For candidal paronychia (confirmed by culture): Topical imidazole lotions as first-line treatment 3
• Regular application of emollients to cuticles and periungual tissues 1
• Critical: Eliminate the source of irritation (moisture, chemicals, repeated trauma) 5

Special Situations

Paronychia with Ingrown Toenail

• Dental floss nail technique to separate lateral nail edge from underlying tissue 1
• Treat the underlying ingrown toenail - antibiotics alone are ineffective 6

Pyogenic Granuloma Formation

• Scoop shave removal with hyfrecation OR silver nitrate application 1, 3
• Alternative: Topical timolol 0.5% gel twice daily under occlusion 1, 3

Refractory Cases

• Intralesional triamcinolone acetonide for recurrent or treatment-refractory cases 1
• Silver nitrate chemical cauterization for excessive granulation tissue 1, 3

Prevention Education

Critical measures to prevent recurrence:

• Trim nails straight across and not too short 1, 3
• Avoid nail biting and cutting nails too short 2
• Keep hands and feet dry - moisture disrupts the protective nail barrier 3
• Wear protective gloves during water or chemical exposure 1, 3
• Daily application of emollients to cuticles and periungual tissues 1, 3
• Wear comfortable, well-fitting shoes and cotton socks 1

Follow-Up Protocol

• Reassess after 2 weeks of treatment 1, 2, 3
• If no improvement or worsening, escalate therapy to surgical intervention 2, 3
• Refer to dermatology or podiatry if no improvement after 2 weeks of appropriate treatment 1, 2, 3

Critical Pitfalls to Avoid

• Do not delay drainage if abscess is present - antibiotics alone will fail 2, 3
• Do not overlook fungal superinfection - present in up to 25% of cases and will not respond to antibacterial therapy 2, 3
• Do not use prolonged topical steroids in chronic paronychia without eliminating the underlying irritant exposure 3
• Do not reflexively prescribe systemic antibiotics for paronychia associated with ingrown toenails unless infection is proven 6