What is the recommended management for an acute bacterial paronychia with pus, including drainage, appropriate oral antibiotics, and consideration of antifungal therapy?

Management of Acute Bacterial Paronychia with Pus

For acute paronychia with pus, immediate drainage is mandatory, followed by warm water or dilute vinegar soaks 3-4 times daily, topical povidone-iodine 2% twice daily, and oral antibiotics (cephalexin or amoxicillin-clavulanate) targeting Staphylococcus aureus and streptococci. 1, 2

Immediate Drainage Protocol

• Any abscess formation mandates drainage as the most critical first intervention 2
• Drainage options range from simple instrumentation with a hypodermic needle to wide incision with scalpel, depending on abscess size and location 2, 3
• For severe cases with pyogenic granuloma or extensive infection, partial nail plate avulsion may be necessary 2
• Obtain bacterial/viral/fungal cultures by swabbing pus before initiating antibiotics to guide definitive therapy 2

Topical Antiseptic Therapy

• Apply topical povidone-iodine 2% twice daily as the most evidence-based first-line antiseptic agent 1, 2
• Implement warm water soaks for 15 minutes 3-4 times daily or white vinegar soaks (1:1 dilution) for 15 minutes daily 2
• Daily dilute vinegar soaks (50:50 dilution) to nail folds for 10-15 minutes twice daily serve as adjunctive measures 1

Oral Antibiotic Selection

• Preferred first-line oral antibiotics are cephalexin or amoxicillin-clavulanate (Augmentin 500/125 mg every 12 hours) for coverage of Staphylococcus aureus and streptococcal species 2
• If cephalexin fails, switch to sulfamethoxazole-trimethoprim (Bactrim) for broader coverage including MRSA 2
• Avoid clindamycin as it lacks adequate coverage for some streptococcal species and has increasing resistance patterns 2
• Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 2, 3

Topical Corticosteroid Therapy

• Apply mid-to-high potency topical corticosteroid ointment to nail folds twice daily to reduce inflammation 1, 2
• Critical caveat: Avoid topical steroids if purulent drainage is present until infection is adequately treated 1
• Resume corticosteroid therapy only after infection control is achieved with drainage and antibiotics 1

Microbiological Considerations

• Up to 25% of paronychia cases have secondary bacterial or mycological superinfections involving both gram-positive and gram-negative organisms 1, 2
• Mixed bacterial flora is present in 73% of acute nail fold infections, with Enterococcus faecalis (14%), Staphylococcus aureus (12%), and Candida albicans (9%) being most common 4
• Empirical therapy should target the most likely pathogens while awaiting culture results 3, 4

Antifungal Consideration

• For candidal paronychia, drainage remains the most important intervention, followed by topical azoles or polyenes for candidal skin infections 2
• Keep the infected area dry as an essential adjunctive measure for fungal paronychia 2
• Consider antifungal therapy only if fungal culture is positive or clinical suspicion is high (chronic paronychia, immunocompromised patients) 5

Follow-Up and Escalation

• Reassess after 2 weeks of treatment 1, 2
• If no improvement is seen, escalate therapy or consider referral to dermatology or podiatry 2
• For intolerable grade 2 or grade 3 paronychia requiring surgical intervention, more complex procedures including partial nail avulsion may be necessary 2

Common Pitfalls to Avoid

• Do not use systemic antibiotics without adequate drainage, as this is ineffective 6, 3
• Do not apply topical steroids while active purulent infection is present 1
• Do not assume single bacterial pathogen—mixed flora is the rule, not the exception 4
• Do not neglect culture collection before starting antibiotics, especially in severe or treatment-refractory cases 2