What is the recommended management for chronic paronychia?

Management of Chronic Paronychia

Chronic paronychia is primarily an inflammatory disorder, not an infection, and should be treated first-line with high-potency topical corticosteroids combined with moisture avoidance and barrier protection—topical antifungals alone are inferior and should not be used as monotherapy. 1, 2, 3

Understanding the Pathophysiology

Chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens that persists for ≥6 weeks. 1, 2 The key insight is that this is not primarily an infectious disease—repeated inflammation leads to fibrosis of the proximal nail fold with poor cuticle generation, which further exposes the nail to irritants and perpetuates the cycle. 2, 3 Secondary bacterial or fungal superinfection occurs in only up to 25% of cases as a complication of the underlying inflammation, not the primary cause. 1, 4, 5

First-Line Conservative Management

Topical Anti-Inflammatory Therapy (Most Critical)

• Apply high-potency topical corticosteroid ointment to the nail folds twice daily—this is more effective than antifungal monotherapy and addresses the underlying inflammatory pathophysiology. 1, 2, 3
• When clinical signs of secondary infection are present (discharge, increased erythema, tenderness), add a topical antibiotic to the corticosteroid regimen. 1
• Consider combination preparations of topical steroids with antibiotics and/or antifungals for convenience and improved adherence. 6

Antiseptic Measures

• Perform antiseptic soaks with 2% povidone-iodine solution or 1:1 dilution of white vinegar in water for 10-15 minutes twice daily. 1, 5
• Apply 2% povidone-iodine directly to the affected area twice daily between soaks. 6, 1, 5
• Warm water soaks alone are also beneficial and can be used 3-4 times daily. 6

Moisture and Irritant Avoidance (Cornerstone of Therapy)

These preventive measures are absolutely essential and form the cornerstone of successful treatment—without addressing moisture exposure, topical therapies will fail. 2, 3

• Keep hands and feet completely dry and avoid prolonged water exposure without protective barriers. 6, 1
• During wet work or chemical exposure, wear cotton gloves beneath waterproof gloves to minimize moisture contact. 6, 1
• Apply emollient ointments to the cuticles and periungual skin daily to restore the protective barrier. 6, 1, 5
• Trim nails straight across, avoiding excessive shortening or trauma to the nail fold. 6, 1, 5

When to Obtain Cultures and Add Antimicrobials

• Obtain bacterial, viral, and fungal cultures if there is discharge, suspected infection, or lack of response to initial conservative therapy within 2 weeks. 6, 1
• Initiate oral antibiotics only when there is evidence of bacterial superinfection (purulent discharge, significant pain, or spreading erythema). 1, 4, 5
• Recognize that both gram-positive and gram-negative bacteria, as well as Candida species, may be isolated from affected sites. 1

Advanced Therapies for Refractory Cases

Novel Topical Options

• Apply timolol 0.5% gel twice daily under occlusion for 1 month—studies have shown complete clearance in refractory cases, especially when pyogenic granuloma is present. 6, 1, 4
• Consider intralesional triamcinolone acetonide for recalcitrant cases that fail topical therapy. 1, 4, 5

Chemical Cauterization

• Use weekly silver nitrate applications to treat excessive granulation tissue—this procedure must be performed by a qualified healthcare professional. 6, 1

Surgical Interventions

If there is insufficient response to 6 months of appropriate medical therapy, surgical treatment is indicated. 7

• Partial nail avulsion may be required when an ingrown nail contributes to the chronic inflammation. 6, 1
• En bloc excision of the proximal nail fold or eponychial marsupialization (with or without nail plate removal) are options for severe refractory cases. 2, 3
• Newer techniques such as the "square flap technique" can remove fibrotic tissue while minimizing nail fold retraction and recovery time. 7

Monitoring and Follow-Up Algorithm

• Reassess after 2 weeks of initial conservative therapy to evaluate response. 6, 1, 5
• If no improvement after 2 weeks of escalated treatment (e.g., addition of oral antibiotics), refer to dermatology or podiatry rather than general surgery. 1, 4, 5
• Continue treatment and preventive measures for at least 2 months, as chronic paronychia requires prolonged therapy. 8

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, 2, 3
• Do not overlook that secondary bacterial or mycological superinfections are present in only up to 25% of cases—they are complications, not the primary problem. 1, 4, 5
• Avoid cutting nails too short or causing trauma to the nail fold, as this perpetuates the inflammatory cycle. 1
• Do not use greasy creams for basic care, topical acne medications, or systemic retinoids, as these can worsen the condition. 4
• Remember that moisture exposure is often occupational—address workplace modifications and continuous prevention strategies for long-term success. 8