What is the most appropriate topical medication for a healthy patient with redness, mild swelling, absence of the cuticle, and a thickened nail plate with horizontal ridges on their left finger, likely due to occupational nail eczema or dermatitis?

Management of Chronic Paronychia with Topical Corticosteroids

The most appropriate topical medication for this patient with chronic paronychia is a topical corticosteroid (such as clobetasol or triamcinolone), not an antifungal, antibiotic, or antihistamine. 1

Clinical Reasoning

This patient presents with classic chronic paronychia: redness and mild swelling of the nail fold, absence of the cuticle, thickened nail plate with horizontal ridges, and a three-month duration in the context of occupational water exposure. 2

Why Topical Corticosteroids Are First-Line

• Chronic paronychia is primarily an inflammatory disorder, not an infectious one, representing a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens from repeated water exposure. 1

• Topical steroid creams have been found to be more effective than antifungals in treating chronic paronychia, contrary to older treatment paradigms. 1

• Mid to high potency topical steroid ointment applied to nail folds twice daily is the recommended approach for inflammation or edema of the nail bed. 3

• The American Contact Dermatitis Society guidelines support application of topical steroids to mitigate flares of dermatitis in occupational hand dermatitis. 2

Why NOT the Other Options

Antifungals (Clotrimazole):

• While Candida can secondarily colonize chronic paronychia, topical antifungals were previously the mainstay but are now recognized as less effective than corticosteroids for the primary inflammatory process. 1
• Antifungals like amorolfine are indicated for onychomycosis, not inflammatory paronychia. 2

Antibiotic Ointment:

• Antibiotics are only indicated when bacterial superinfection is present (purulent drainage, severe pain). 2
• This patient has mild chronic inflammation without signs of acute infection. 1
• The American Contact Dermatitis Society specifically warns against products containing topical antibiotics (neomycin, bacitracin) as they can cause allergic contact dermatitis. 2

Antihistamines (Diphenhydramine):

• Topical antihistamines have no role in treating inflammatory nail fold disorders. 4
• Oral antihistamines are not recommended for eczematous conditions as they do not reduce inflammation. 4

Complete Management Algorithm

Immediate Treatment

• Apply mid to high potency topical corticosteroid ointment (e.g., clobetasol 0.05% or triamcinolone 0.1%) to the affected nail fold twice daily. 3, 1

Essential Preventive Measures (Cornerstone of Therapy)

• Keep hands dry and out of water when possible; this is mandatory as repeated water exposure perpetuates the inflammatory cycle. 3, 1
• Wear waterproof gloves with cotton liners when water exposure is unavoidable for occupational reasons. 2
• Apply moisturizer after hand washing and before wearing gloves to protect the skin barrier. 2
• Avoid irritants including harsh soaps, detergents, and very hot or cold water. 2

Follow-Up Strategy

• Reassess after 2 weeks of treatment; if not improving, consider stronger topical steroids or alternative diagnoses. 3
• For recalcitrant cases, surgical options (eponychial marsupialization) or systemic therapy may be necessary. 1

Critical Pitfalls to Avoid

• Do not assume this is a fungal infection requiring antifungals just because it involves the nail—chronic paronychia is inflammatory, not infectious. 1
• Do not use topical antibiotics prophylactically as they increase risk of allergic contact dermatitis without addressing the underlying inflammation. 2
• Do not neglect occupational modification—without reducing water exposure, topical treatment alone will likely fail. 1
• Avoid prolonged high-potency steroid use on thin skin areas to prevent skin atrophy, but short-term use on nail folds is appropriate. 2