What is the recommended treatment for an adult patient with normal renal function and no known allergy to penicillin (penicillin) presenting with paronychia?

Treatment of Paronychia in Adults Without Penicillin Allergy

For acute paronychia in an adult with normal renal function and no penicillin allergy, treatment should begin with warm water soaks and topical therapy, reserving oral antibiotics only for cases with significant surrounding cellulitis or when drainage alone is insufficient. 1

Initial Assessment and Conservative Management

The first step is determining whether an abscess is present, which mandates drainage. 1 Conservative treatment consists of:

• Warm water soaks (or Burow solution/1% acetic acid soaks) for 15 minutes, 3-4 times daily 1, 2
• Topical antibiotics with or without topical steroids when simple soaks fail to relieve inflammation 1
• This approach is effective for early-stage infections without abscess formation 1

Drainage Procedures

When an abscess is present, drainage is mandatory and can be accomplished through several techniques ranging from instrumentation with a hypodermic needle to wide incision with a scalpel. 1 An intra-sulcal approach is preferable to a nail fold incision for paronychia not associated with an ingrown toenail. 3

Oral Antibiotic Therapy

Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or a severe infection with surrounding cellulitis is present. 1

When oral antibiotics are indicated, therapy should be based on the most likely pathogens:

• Acute paronychia is typically caused by polymicrobial infections, most commonly Staphylococcus aureus in adults 1, 4
• In pediatric populations with finger-sucking habits, mixed anaerobic and aerobic infections predominate, but this is less relevant for typical adult presentations 5
• Amoxicillin-clavulanate or clindamycin provides appropriate broad-spectrum coverage when oral therapy is needed 5
• Duration is typically 7-10 days for bacterial infections requiring systemic treatment 6

Chronic Paronychia Management

Chronic paronychia (symptoms ≥6 weeks) represents an irritant contact dermatitis rather than an infectious process and requires a different approach:

• Topical very potent steroids are first-line treatment 2
• Topical antifungals and antiseptics should be applied as necessary, particularly when Candida species are present 2, 7
• Imidazole lotion alternating with antibacterial lotion is effective for yeast-associated paronychia 2
• Treatment may require several months until cuticle integrity is restored 2
• Combination topical preparations containing insulating polymers, antifungals (octopirox, climbazole), and anti-inflammatory agents show promise for occupational cases 7

Common Pitfalls to Avoid

• Do not prescribe oral antibiotics routinely for simple acute paronychia that can be drained adequately 1
• Do not treat chronic paronychia primarily with antibiotics—it is an inflammatory condition requiring topical steroids and removal of irritants 1, 4
• Avoid prolonged soaking in soapy water as this worsens chronic paronychia 2
• Do not overlook secondary fungal colonization in chronic cases, which requires concurrent antifungal therapy 3, 7

Monitoring and Follow-up

• Reassess within 48-72 hours if no clinical improvement occurs 6
• For chronic paronychia, treatment may take weeks to months and patient education about avoiding irritants is paramount to prevent recurrence 1
• Consider dermatology consultation for chronic paronychia unresponsive to standard treatment, as unusual causes including malignancy must be excluded 3