Treatment for Paronychia
For acute paronychia, start with warm water or dilute vinegar soaks (1:1 dilution) 3-4 times daily for 15 minutes combined with topical 2% povidone-iodine twice daily and a mid-to-high potency topical corticosteroid ointment to the nail folds twice daily. 1, 2
Acute Paronychia Management Algorithm
Grade 1 (Mild): Erythema and edema without purulent drainage
First-line topical therapy:
- Apply 2% povidone-iodine to nail folds twice daily for 10-15 minutes 1, 2, 3
- Immediately follow with mid-to-high potency topical corticosteroid ointment (not cream) to nail folds twice daily 1, 2
- Add warm water soaks 3-4 times daily for 15 minutes OR dilute vinegar soaks (50:50 dilution) once daily for 15 minutes 1, 2
No oral antibiotics needed at this stage unless immunocompromised 2
Grade 2 (Moderate): Nail fold edema/erythema with pain, discharge, or nail plate separation
Add oral antibiotics if infection suspected:
Critical step: Obtain bacterial/viral/fungal cultures before starting antibiotics if purulent drainage present 2, 3
Taping technique: Tape the nail fold away from the nail plate to reduce mechanical trauma 1
Grade 3 (Severe): Intolerable symptoms or abscess formation
Oral antibiotics required with culture-directed therapy 2
Stop topical steroids immediately if purulent drainage develops as steroids worsen infection 1, 3
Chronic Paronychia Management (≥6 weeks duration)
Chronic paronychia is primarily an inflammatory/irritant dermatitis, not an infection, requiring a fundamentally different approach. 4, 6
First-line treatment:
- Identify and eliminate irritant exposures (water, chemicals, detergents) 4, 6
- Topical corticosteroids are more effective than antifungals for chronic paronychia 6
- Apply mid-to-high potency topical steroid ointment twice daily for weeks to months 6
- Alternative: Topical calcineurin inhibitors if steroids fail 4
Adjunctive measures:
- Keep affected area dry at all times 2
- Daily application of topical emollients to cuticles and periungual tissues 5, 1
- Wear gloves during wet work 5, 1
Refractory chronic paronychia:
- Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in drug-induced cases 5, 2
- Silver nitrate chemical cauterization 5, 2
- Cryotherapy for pyogenic granuloma 5
- Surgical options: En bloc excision of proximal nail fold or eponychial marsupialization 6
Critical Clinical Considerations
Up to 25% of paronychia cases have secondary bacterial or fungal superinfections involving both gram-positive and gram-negative organisms. 5, 1, 2, 3 This means:
- Always obtain cultures before antibiotics in moderate-to-severe cases 2, 3
- For candidal paronychia specifically, drainage is most important, followed by topical azoles/polyenes 2
- Antibiotic-resistant acute paronychia may be viral, fungal, drug-induced, or autoimmune (pemphigus vulgaris) 7
Common Pitfalls to Avoid
- Never use antiseptic soaks alone without addressing mechanical nail impingement in ingrown toenails 1
- Reassess after 2 weeks: If no improvement or worsening, escalate therapy or refer to dermatology/podiatry 5, 1, 2
- Monitor for osteomyelitis in chronic cases, as nail folds are anatomically close to phalanges 8
- Oral antibiotics are usually unnecessary if adequate drainage achieved unless immunocompromised or severe infection 2, 4