What is the recommended treatment for acute and chronic paronychia, including topical care, indications for oral antibiotics, incision and drainage, and preventive measures for chronic cases?

Paronychia Treatment Guidelines

Acute Paronychia Management

For acute paronychia, start with antiseptic soaks using dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily, combined with topical 2% povidone-iodine application twice daily to the affected area. 1

Initial Conservative Treatment (Grade 1-2)

• Apply mid to high-potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1
• Continue antiseptic soaks with dilute vinegar or povidone-iodine for 10-15 minutes twice daily 1
• Apply topical 2% povidone-iodine directly to the affected area twice daily between soaks 1
• For mild cases with only nail fold edema or erythema, topical antibiotics combined with corticosteroids may be sufficient 2

Indications for Oral Antibiotics

Oral antibiotics are indicated when there is nail fold edema or erythema with pain, discharge, nail plate separation, or suspected bacterial superinfection. 2

• Recognize that secondary bacterial or mycological superinfections occur in up to 25% of paronychia cases, with both gram-positive and gram-negative organisms implicated 2, 1
• Obtain bacterial, viral, and fungal cultures if infection is suspected before starting antibiotics 2
• If initial treatment with cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 3

Incision and Drainage Indications

• Check for presence of pus or abscess formation which requires drainage 1
• For grade 3 paronychia (severe cases limiting self-care activities) or intolerable grade 2, surgical intervention with partial nail avulsion may be necessary 2
• Silver nitrate chemical cauterization is indicated for excessive granulation tissue 2, 1

Reassessment Protocol

Reassess after 2 weeks of treatment; if no improvement occurs, escalate therapy or consider specialist referral. 2, 1

Chronic Paronychia Management

Chronic paronychia is primarily an irritant-mediated inflammatory disorder, not an infectious disease, and high-potency topical corticosteroids are more effective than antifungal monotherapy. 1, 4

First-Line Treatment

• Apply high-potency topical corticosteroid ointment to nail folds twice daily as the primary treatment 2, 1
• Add topical antibiotics to the corticosteroid regimen when clinical signs of secondary infection are present (discharge, increased erythema, tenderness) 1
• Perform antiseptic soaks with 2% povidone-iodine or 1:1 vinegar dilution for 10-15 minutes twice daily 1
• Apply emollient ointments to cuticles and periungual skin daily to restore the protective barrier 2, 1

Advanced Therapies for Refractory Cases

• Apply topical timolol 0.5% gel twice daily under occlusion for 1 month, which has shown complete clearance in refractory cases with pyogenic granuloma 2, 1
• Use weekly silver nitrate applications for excessive granulation tissue 1
• Consider intralesional triamcinolone acetonide for recurrent, severe, or treatment-refractory cases 1
• Partial nail avulsion may be required when ingrown nail contributes to chronic inflammation 1

Preventive Measures for Chronic Cases

Prevention is the cornerstone of chronic paronychia management and must be systematically promoted. 2, 4

Moisture and Irritant Avoidance

• Keep hands and feet completely dry and avoid prolonged water exposure without protective barriers 1
• Wear cotton gloves beneath waterproof gloves during wet work or chemical exposure 1
• Avoid repeated friction, trauma, and excessive pressure to the nail area 2, 1

Proper Nail Care

• Trim nails straight across, avoiding excessive shortening or trauma to the nail fold 2, 1
• Avoid biting nails or cutting nails too short 2
• Wear comfortable well-fitting shoes and cotton socks for toenail paronychia 2
• Consider preventive correction of nail curvature with referral to a podiatrist if needed 2

Specialist Referral Pathway

Refer to dermatology or podiatry (not general surgery) when paronychia does not improve after 2 weeks of appropriate treatment. 5

• For toenail paronychia with complications, podiatry consultation is preferred given their expertise in nail fold pathology 5
• Hand surgery consultation should be reserved specifically for severe or treatment-refractory finger paronychia requiring advanced surgical intervention 5

Key Clinical Pitfalls

• Do not manage chronic paronychia primarily as a fungal infection; topical steroids provide superior outcomes compared with antifungal agents alone 1, 4
• Avoid reflexive general surgery referral, as this condition is managed primarily by dermatology and podiatry 5
• Do not cut nails too short or cause trauma to the nail fold, as this perpetuates the inflammatory cycle 1
• Obtain cultures when there is discharge, suspected infection, or lack of response to initial therapy within 2 weeks 1