What is the appropriate management of peri‑ungual eczema (eczema affecting the nail folds) in an adult?

Management of Periungual Eczema in Adults

For periungual eczema affecting the nail folds, apply a mid-to-high potency topical corticosteroid ointment to the nail folds twice daily, combined with gentle skin care and daily emollient application to the cuticles and periungual tissues. 1, 2, 3

Initial Assessment and Diagnosis

Before initiating treatment, examine for:

• Extent and severity of periungual inflammation - look for erythema, edema, and scaling of the nail folds 1
• Signs of secondary infection - crusting, weeping, purulent discharge, or warmth suggest bacterial superinfection 1, 2
• Nail plate involvement - check for pitting, ridging, or onycholysis that may indicate psoriasis rather than eczema 1
• Aggravating factors - exposure to irritants (soaps, detergents, water), occupational exposures 1

Treatment Algorithm

First-Line Therapy (Mild Periungual Eczema)

Topical corticosteroids:

• Apply mid-to-high potency topical corticosteroid ointment (such as triamcinolone 0.1% or betamethasone valerate 0.1%) to affected nail folds twice daily 1, 2, 4
• Potent and moderate topical corticosteroids are significantly more effective than mild corticosteroids for eczema treatment 4, 5
• Once-daily application is as effective as twice-daily for potent corticosteroids, but twice-daily may be preferred initially for moderate-potency agents 4

Adjunctive measures:

• Daily emollient application to cuticles and periungual tissues to restore the skin barrier 1, 2, 3
• Use a dispersible cream as soap substitute rather than traditional soaps that strip natural lipids 1
• Avoid irritants - wear gloves during cleaning, avoid excessive water exposure 1, 3, 6
• Keep nails short but not too short, trim straight across 1, 3, 6

If Infection is Suspected

Do not use topical corticosteroids if purulent drainage is present until infection is adequately treated 1, 2

For suspected bacterial infection:

• Obtain bacterial/viral/fungal cultures before starting antibiotics 1, 2, 3
• Add topical povidone-iodine 2% twice daily as first-line antiseptic 1, 2, 3
• Consider dilute vinegar soaks (50:50 dilution) for 10-15 minutes twice daily 1, 2
• If moderate infection with systemic signs, add oral antibiotics (cephalexin or amoxicillin-clavulanate) 3, 6
• Up to 25% of periungual inflammatory conditions have secondary bacterial or fungal superinfection 1, 3, 6

Reassessment and Escalation

Reassess after 2 weeks of treatment 1, 2, 3:

• If improved, continue treatment and consider tapering to intermittent maintenance (twice weekly application) to prevent relapse 4, 7
• Weekend (proactive) therapy with topical corticosteroids reduces relapse likelihood from 58% to 25% 4
• If no improvement or worsening, consider:
  • Increasing corticosteroid potency (e.g., from moderate to potent) 4, 5
  • Intralesional triamcinolone acetonide 5-10 mg/cc for refractory cases involving nail matrix 1
  • Referral to dermatology for alternative diagnoses or advanced therapies 6

Important Clinical Considerations

Corticosteroid Potency Selection

• Potent corticosteroids (betamethasone dipropionate 0.05%, mometasone furoate 0.1%) are more effective than moderate-potency agents for moderate-to-severe eczema 4, 5
• Very potent corticosteroids (clobetasol propionate 0.05%) show uncertain additional benefit over potent corticosteroids for short-term use 4
• The periungual area has relatively thick skin, making moderate-to-potent corticosteroids appropriate 5

Safety Profile

• Short-term use (median 3 weeks) of potent topical corticosteroids shows no evidence of increased skin thinning 5
• Abnormal skin thinning occurred in only 1% of participants across trials, with most cases from very potent corticosteroids 4
• Application-site reactions are least likely with topical corticosteroids compared to calcineurin inhibitors 5

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia - explain that appropriate short-term use of potent corticosteroids is safe and effective 1, 4
• Using topical steroids on infected eczema - always treat infection first or concurrently 1, 2
• Inadequate emollient use - emollients are essential adjuncts, not optional 1
• Cutting nails too short - this can cause trauma and worsen periungual inflammation 3, 6

Alternative Diagnoses to Consider

If treatment fails after 2-4 weeks, reconsider the diagnosis:

• Psoriasis - look for nail pitting, salmon patches, or psoriatic plaques elsewhere 1
• Contact dermatitis - consider patch testing for occupational or cosmetic allergens 1
• Chronic paronychia - may require different management with antifungals if Candida is involved 3, 6

Maintenance Therapy

Once remission is achieved:

• Transition to intermittent application (2 applications per week, typically on weekends) to maintain remission 4, 7
• Continue daily emollient application indefinitely 1
• Avoid known triggers and maintain protective measures (gloves, gentle cleansers) 1, 3