What is the appropriate management of acute and chronic paronychia?

Management of Acute and Chronic Paronychia

Acute Paronychia

For acute paronychia, begin with antiseptic soaks using 2% povidone-iodine or 1:1 diluted white vinegar for 10-15 minutes twice daily, combined with topical 2% povidone-iodine application and mid-to-high potency topical corticosteroid ointment to the nail folds twice daily; if an abscess is present, immediate surgical drainage is mandatory before considering antibiotics. 1, 2

Initial Assessment

• Evaluate severity based on degree of erythema, edema, presence of purulent discharge, granulation tissue formation, and whether an abscess requiring drainage is present 1, 2
• Check specifically for fluctuance or pus collection, which mandates immediate surgical drainage rather than antibiotics alone 3
• Identify predisposing factors including ingrown toenail (onychocryptosis), occupational water/chemical exposure, or medication-induced causes (particularly EGFR tyrosine kinase inhibitors) 1, 2
• Obtain bacterial, viral, and fungal cultures before initiating antimicrobial therapy, as up to 25% of cases involve secondary bacterial or mycological superinfections 4, 3

Grade 1 (Mild): Nail Fold Edema or Erythema with Cuticle Disruption

• Implement antiseptic soaks with 2% povidone-iodine or 1:1 diluted white vinegar for 10-15 minutes twice daily 1, 2
• Apply topical 2% povidone-iodine directly to the affected area twice daily 4, 1, 3
• Apply mid-to-high potency topical corticosteroid ointment to nail folds twice daily 1, 2
• Continue current medication dose and monitor for change in severity 4
• Reassess after 2 weeks; if no improvement or worsening, escalate to Grade 2 treatment 4, 2

Grade 2 (Moderate): Pain with Discharge or Nail Plate Separation

• Continue all Grade 1 interventions 4
• Add oral antibiotics: first-line is cephalexin or amoxicillin-clavulanate 2
• If initial therapy with cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1, 3
• Obtain bacterial, viral, and fungal cultures if infection is suspected 4
• Reassess after 2 weeks; if no improvement or worsening, escalate to Grade 3 treatment 4, 2

Grade 3 (Severe): Surgical Intervention Indicated or Limiting Self-Care Activities

• Interrupt causative medication until Grade 0/1 if drug-induced 4
• Perform immediate surgical drainage for any abscess formation 3, 2
• Continue topical 2% povidone-iodine and topical corticosteroids 4
• Administer oral antibiotics after drainage 4, 2
• Consider partial nail avulsion if onychocryptosis is contributing 4, 1
• Apply silver nitrate chemical cauterization for excessive granulation tissue 4, 1
• Reassess after 2 weeks; if no improvement, dose interruption or discontinuation of causative medication may be necessary 4

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Chronic Paronychia (≥6 Weeks Duration)

Chronic paronychia is primarily an irritant-mediated inflammatory disorder, not an infectious disease, and high-potency topical corticosteroids are more effective than antifungals and should be first-line treatment, applied twice daily to the nail folds, combined with strict moisture avoidance and barrier protection. 1, 2, 5

Pathophysiology Understanding

• Chronic paronychia is an irritant-mediated inflammatory disorder of the proximal nail fold that persists for ≥6 weeks, rather than a primary infectious disease 1
• Secondary bacterial or fungal superinfection occurs in up to 25% of cases as a complication of underlying inflammation 1
• Repeated inflammation leads to fibrosis of the proximal nail fold with poor cuticle generation, which further exposes the nail to irritants 5

First-Line Conservative Therapy

Topical Anti-Inflammatory Treatment:

• Apply high-potency topical corticosteroid ointment to nail folds twice daily; this is more effective than antifungal monotherapy 1, 2, 5
• When clinical signs of secondary infection (discharge, increased erythema, tenderness) are present, add a topical antibiotic to the regimen 1

Antiseptic Measures:

• Perform antiseptic soaks with 2% povidone-iodine or 1:1 diluted white vinegar for 10-15 minutes twice daily 1
• Apply 2% povidone-iodine directly to the affected area twice daily between soaks 4, 1

Preventive Measures (Critical for Success):

• Keep hands and feet completely dry and avoid prolonged water exposure without protective barriers 1, 2
• Wear cotton gloves beneath waterproof gloves during wet work or chemical exposure 1, 2
• Apply emollient ointments to cuticles and periungual skin daily to restore the protective barrier 4, 1, 2
• Trim nails straight across, avoiding excessive shortening or trauma to the nail fold 1, 2

When to Obtain Cultures

• Obtain bacterial, viral, and fungal cultures if there is discharge, suspected infection, or lack of response to initial conservative therapy within 2 weeks 1
• Recognize that both gram-positive and gram-negative bacteria (Enterococcus faecalis, Staphylococcus aureus, Enterobacter cloacae, Klebsiella pneumoniae), as well as Candida species, may be isolated 1, 6

Antimicrobial Therapy for Confirmed Superinfection

• Initiate oral antibiotics only when there is evidence of bacterial superinfection (purulent discharge, significant pain, or spreading erythema) 1
• For Candida-associated paronychia confirmed by culture, use topical imidazole lotions as first-line treatment 3
• If initial therapy fails, consider sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 1

Advanced/Refractory Therapies

Novel Topical Options:

• Apply timolol 0.5% gel twice daily under occlusion for 1 month; studies show complete clearance in refractory cases, especially with pyogenic granuloma 4, 1

Chemical Cauterization:

• Use weekly silver nitrate applications for excessive granulation tissue; this must be performed by a qualified healthcare professional 4, 1

Procedural Interventions:

• Partial nail avulsion may be required when an ingrown nail contributes to chronic inflammation 1
• En bloc excision of the proximal nail fold or eponychial marsupialization can be considered for recalcitrant cases 5

Monitoring and Follow-Up

• Reassess after 2 weeks of initial conservative therapy to evaluate response 4, 1, 2
• If no improvement after 2 weeks of escalated treatment, refer to dermatology or podiatry rather than general surgery 1, 3

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Critical Pitfalls to Avoid

• Do not manage chronic paronychia primarily as a fungal infection; topical steroids provide superior outcomes compared with antifungal agents alone 1, 5
• Do not use antibiotics alone when an abscess is present; surgical drainage is mandatory first 3, 2
• Do not overlook moisture exposure as the primary driver in chronic paronychia; elimination of irritant exposure is essential for cure 1, 5
• Do not cut nails too short or cause trauma to the nail fold, as this perpetuates the inflammatory cycle 1, 2
• Do not reflexively refer to general surgery; paronychia is managed primarily by dermatology and podiatry 3
• Monitor for progression to osteomyelitis in chronic cases, as nail folds are anatomically close to phalanges 7