What is the recommended treatment for a patient with chronic paronychia, possibly with a history of eczema or psoriasis?

Treatment of Chronic Paronychia

For chronic paronychia, initiate treatment with mid-to-high potency topical corticosteroid ointment applied to the nail folds twice daily combined with topical 2% povidone-iodine twice daily, along with warm water or dilute white vinegar soaks (1:1 dilution) for 15 minutes, 3-4 times daily. 1

Understanding Chronic Paronychia

Chronic paronychia is fundamentally an inflammatory disorder, not primarily an infectious condition, though secondary infections commonly develop. 2, 3 This distinction is critical because it shifts treatment away from antifungals as first-line therapy toward anti-inflammatory agents. The condition results from repeated inflammation causing fibrosis of the proximal nail fold with poor cuticle generation, creating a cycle of ongoing exposure to irritants. 2

First-Line Treatment Approach

Topical Anti-Inflammatory Therapy

• Apply mid-to-high potency topical corticosteroid ointment to nail folds twice daily as the cornerstone of treatment, which has proven more effective than antifungals for chronic paronychia. 1, 2
• Combine with topical 2% povidone-iodine applied twice daily to provide antiseptic coverage. 1, 4

Antiseptic Soaks

• Perform warm water soaks for 15 minutes, 3-4 times daily, or alternatively use white vinegar soaks (1:1 dilution) for 15 minutes daily. 1, 3
• These soaks reduce inflammation and help prevent secondary bacterial or fungal superinfection. 1

Avoidance of Irritants

• Identify and eliminate occupational or household irritants including acids, alkalis, excessive moisture, and chemicals commonly encountered by housekeepers, dishwashers, bartenders, florists, and bakers. 5, 3
• Wear protective gloves during wet work to prevent ongoing irritant exposure. 1, 4

Management of Secondary Infections

Up to 25% of chronic paronychia cases develop secondary bacterial or fungal superinfections. 1

When Candida is Present

• Topical azoles or polyenes are effective for candidal involvement. 1
• Keep the infected area dry as moisture promotes candidal growth. 1
• For severe candidal involvement with nail changes, consider oral fluconazole 50 mg daily or 300 mg weekly for minimum 4 weeks for fingernails. 6, 7
• Itraconazole 200 mg daily or pulse therapy (400 mg daily for 1 week per month) is first-line for Candida onychomycosis when systemic therapy is needed, given shorter treatment duration and better cost-effectiveness. 6

When Bacterial Infection is Present

• If signs of active infection develop (increased pain, purulent discharge), initiate oral antibiotics with cephalexin or amoxicillin-clavulanate (500/125 mg every 12 hours). 1
• If cephalexin fails, use sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA. 1
• Avoid clindamycin due to inadequate streptococcal coverage and increasing resistance. 1

Surgical Intervention for Refractory Cases

Indications for Surgery

• Any abscess requires drainage, ranging from needle instrumentation to wide incision with scalpel. 1
• For intolerable grade 2 or grade 3 paronychia with pyogenic granuloma, perform partial nail plate avulsion. 1
• En bloc excision of the proximal nail fold or eponychial marsupialization may be necessary for truly recalcitrant cases. 2

Advanced Non-Surgical Options

• Topical timolol 0.5% gel applied twice daily under occlusion for 1 month has shown complete clearance in refractory cases. 1, 4
• Silver nitrate chemical cauterization can be applied weekly for persistent granulation tissue. 1, 4

Special Considerations for Patients with Eczema or Psoriasis

• Patients with underlying inflammatory dermatoses require aggressive topical corticosteroid therapy as their baseline inflammatory state predisposes to chronic paronychia. 2
• Terbinafine can aggravate psoriasis, so if systemic antifungal therapy is needed, prefer itraconazole or fluconazole. 6
• These patients benefit from daily application of topical emollients to cuticles and periungual tissues to maintain skin barrier function. 1, 8

Follow-Up and Prevention

Monitoring

• Reassess after 2 weeks of treatment to evaluate response. 1, 4
• If no improvement, consider referral to dermatology for further evaluation and possible surgical intervention. 1, 4

Long-Term Prevention

• Avoid nail biting and cutting nails too short; trim nails straight across. 1, 8
• Never cut cuticles or manipulate nail folds as this breaches the protective barrier. 1, 8
• Apply emollients daily to cuticles and periungual tissues to maintain barrier integrity. 1, 8
• Wear comfortable, well-fitting shoes and cotton socks for toenail involvement. 1

Common Pitfalls to Avoid

• Do not treat chronic paronychia primarily with antifungals—this is an inflammatory condition requiring corticosteroids as first-line therapy. 2, 3
• Do not prescribe oral antibiotics without evidence of active infection or adequate abscess drainage—chronic paronychia is not primarily infectious. 1, 3
• Do not overlook occupational or household irritant exposure—treatment will fail without eliminating the underlying cause. 3
• Do not expect rapid resolution—chronic paronychia treatment may take weeks to months. 3