What is the appropriate treatment for acute or chronic paronychia in an adult?

Treatment of Paronychia

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

Acute Paronychia Management

First-Line Conservative Treatment

• Implement antiseptic soaks using either warm water 3-4 times daily or white vinegar soaks (1:1 dilution with water) for 15 minutes daily 1, 2
• Apply topical 2% povidone-iodine twice daily directly to the affected periungual area 1, 2
• Use mid-to-high potency topical corticosteroid ointment to the nail folds twice daily to reduce inflammation 1, 2

When to Add Oral Antibiotics

• Start oral antibiotics if signs of infection are present (increased warmth, purulence, spreading erythema, or systemic symptoms) 1
• First-line antibiotic: Cephalexin is the preferred initial agent 1
• Second-line antibiotic: Amoxicillin-clavulanate (Augmentin) 500/125 mg every 12 hours provides broader coverage 1
• If cephalexin fails: Switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1, 2
• Avoid clindamycin as it lacks adequate streptococcal coverage and has increasing resistance patterns 1

Surgical Drainage Indications

• Any abscess formation mandates drainage regardless of other treatment 1
• Drainage options range from simple instrumentation with a hypodermic needle to wide incision with scalpel 1, 3
• Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 1, 3

Critical Pitfall to Avoid

• Obtain bacterial cultures before starting antibiotics in severe cases or treatment failures, as up to 25% of paronychia cases have secondary bacterial or mycological superinfections 1, 2
• Swab any pus for culture and adjust antibiotics based on results 1

Chronic Paronychia Management

Pathophysiology Understanding

• Chronic paronychia is primarily an irritant contact dermatitis, not an infection, occurring when the protective cuticle barrier is breached 4, 3
• Common in patients with wet occupations (housekeepers, dishwashers, bartenders, florists, bakers, swimmers) or children who suck their thumbs 4, 3
• Microorganisms (both yeasts and bacteria) are secondary colonizers, not primary pathogens 4

Treatment Approach

• Primary goal: Stop the source of irritation and restore the protective nail barrier 3
• Apply high-potency topical corticosteroids alone or combined with topical antibiotics 2
• Keep the infected area dry - this is the most important intervention for candidal paronychia 1
• Regular application of emollients to cuticles and periungual tissues 2
• Treatment may take weeks to months to achieve resolution 3

Severe or Refractory Cases

Advanced Interventions

• For pyogenic granuloma formation: Perform scoop shave removal with hyfrecation or silver nitrate application 2, 5
• For intolerable grade 2 or grade 3 paronychia: Surgical intervention including partial nail plate avulsion may be necessary 1
• For recurrent or treatment-refractory cases: Consider intralesional triamcinolone acetonide 2, 5
• Alternative option: Topical timolol 0.5% gel twice daily under occlusion for 1 month has shown complete clearance in periungual pyogenic granulomas 1, 2

Follow-Up Protocol

• Reassess after 2 weeks of treatment 1, 2
• If no improvement after 2 weeks: Escalate therapy or consider referral to dermatology or podiatry 1, 2
• Monitor for progression to osteomyelitis in chronic cases, as nail folds are anatomically close to phalanges 6

Prevention Education

Critical preventive measures to discuss:

• Avoid nail biting or cutting nails too short 1
• Trim nails straight across, ensuring they are not too short 1, 2
• Apply topical emollients daily to cuticles and periungual tissues 1, 2
• Wear gloves during cleaning or activities involving water/chemicals 1, 2
• Wear comfortable, well-fitting shoes and cotton socks for toenail paronychia 1, 2