How do you treat paronychia (cuticle infection)?

Treatment of Paronychia (Cuticle Infection)

For acute paronychia with abscess or significant swelling, immediate surgical incision and drainage is the priority, followed by topical 2% povidone-iodine twice daily; oral antibiotics are reserved only for severe infections or when drainage alone fails. 1, 2

Initial Assessment and Triage

Determine the severity and type of paronychia to guide treatment:

• Grade 1: Mild erythema and edema without purulence 2
• Grade 2: Moderate inflammation with pain, discharge, or nail plate separation 2
• Grade 3: Severe infection with abscess formation or intolerable symptoms 2

Check for fluctuance or pus—if present, this mandates immediate surgical drainage rather than antibiotics alone. 1, 3

Acute Paronychia Management

Surgical Drainage (When Indicated)

• Perform immediate incision and drainage for any abscess with significant swelling or purulent drainage 1, 4
• Multiple drainage techniques exist, from needle instrumentation to wide scalpel incision 4
• Obtain bacterial, viral, and fungal cultures from purulent drainage before initiating antimicrobial therapy 1, 3

Topical Therapy (First-Line for All Cases)

• Apply topical 2% povidone-iodine twice daily as the primary antiseptic agent—this is the most evidence-based first-line treatment 1, 2, 3
• Perform antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1, 2
• Warm soaks with or without Burow solution or 1% acetic acid reduce inflammation 4

Oral Antibiotics (Reserved for Specific Situations)

Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present. 4

When oral antibiotics are indicated:

• Reserve for grade 2 or higher cases with suspected bacterial infection after obtaining cultures, or when topical therapy fails after 2 weeks 2
• For green pus suggesting Pseudomonas aeruginosa, start oral fluoroquinolone (ciprofloxacin or levofloxacin) immediately 1
• For suspected MRSA or treatment failure, consider sulfamethoxazole-trimethoprim 3
• Base therapy on most likely pathogens and local resistance patterns 4

Chronic Paronychia Management

Chronic paronychia is primarily an irritant dermatitis, not an infection—treatment focuses on eliminating irritant exposure and reducing inflammation. 4

Primary Treatment Approach

• Combine topical 2% povidone-iodine twice daily with high-potency topical corticosteroids applied to nail folds twice daily 2, 3
• Alternatively, use topical calcineurin inhibitors for inflammation 4
• Treatment may take weeks to months 4

Addressing Secondary Infections

Secondary bacterial or fungal superinfections occur in up to 25% of paronychia cases. 1, 3

• For Candida-associated paronychia confirmed by culture, use topical imidazole lotions as first-line treatment 3
• Azole drugs (miconazole, clotrimazole, ketoconazole) are preferred for yeast infections 5
• For severe candidiasis, add oral fluconazole 100 mg for 20 days 6
• Avoid topical steroids if purulent drainage is present until infection is adequately treated 2

Escalation for Refractory Cases

Reassess after 2 weeks; if no improvement, escalate therapy or consider surgical intervention. 2, 3

• For grade 3 or intolerable grade 2 paronychia not responding to medical management, consider partial nail avulsion 2, 3
• Silver nitrate chemical cauterization can treat excessive granulation tissue 3
• Refer to dermatology or podiatry when paronychia does not improve after 2 weeks of appropriate treatment 3

Prevention of Recurrence

• Trim nails straight across and not too short to prevent trauma 1, 3
• Keep hands and feet dry, as moisture disrupts the protective nail barrier 3
• Wear protective gloves during water exposure or chemical handling 1, 3
• Apply emollients regularly to cuticles and periungual tissues daily 3

Critical Pitfalls to Avoid

• Do not use systemic antibiotics reflexively—they are ineffective unless infection is proven, especially for ingrown nails 7
• Do not overlook potential secondary fungal infections, which will not respond to antibacterial therapy alone 3
• Do not use prolonged topical steroids without addressing the underlying irritant exposure in chronic paronychia 3
• Patient education is paramount to reduce recurrence of both acute and chronic paronychia 4