What is the appropriate management for acute paronychia of my middle finger?

Management of Acute Paronychia of the Middle Finger

Start with warm antiseptic soaks 3–4 times daily combined with topical 2% povidone-iodine twice daily, add a mid-to-high potency topical corticosteroid to the nail folds twice daily, and reserve oral antibiotics only if you see clear signs of infection such as purulence, spreading erythema, increased warmth, or systemic symptoms. 1

Initial Conservative Management (First-Line for All Cases)

Antiseptic Soaks

• Perform warm water soaks or use a 1:1 white vinegar-to-water solution for approximately 15 minutes, 3–4 times daily 1
• This mechanical intervention helps reduce bacterial load and promotes drainage 1

Topical Therapy

• Apply 2% povidone-iodine directly to the affected periungual area twice daily 1, 2
• Apply a mid-to-high potency topical corticosteroid ointment to the nail folds twice daily to reduce the inflammatory component 1, 2
• This dual approach addresses both microbial colonization and inflammation simultaneously 1

When to Add Oral Antibiotics

Only initiate systemic antibiotics when clinical signs of true infection are present, including increased warmth, purulent discharge, spreading erythema beyond the immediate nail fold, or systemic symptoms like fever 1. The majority of early acute paronychia cases resolve with conservative measures alone 1, 3.

Antibiotic Selection Algorithm

• First-line: Cephalexin is the preferred initial oral agent 1
• Second-line (if cephalexin fails or broader coverage needed): Switch to sulfamethoxazole-trimethoprim, which covers MRSA 1, 4
• Alternative second-line: Amoxicillin-clavulanate 500/125 mg every 12 hours provides broader gram-negative and anaerobic coverage 1
• Avoid clindamycin due to inadequate streptococcal coverage and rising resistance rates 1

Critical Caveat on Microbiology

Up to 25% of paronychia cases involve secondary bacterial or fungal superinfection 1, 4. If you see purulent discharge or the case is severe/refractory, obtain bacterial and fungal cultures before starting antibiotics to guide definitive therapy 1, 2. Mixed flora is common, with Enterococcus faecalis, Staphylococcus aureus, Candida albicans, and gram-negative organisms frequently isolated 5.

Surgical Drainage Indications

Any fluctuance or abscess formation mandates immediate incision and drainage, regardless of other treatments 1, 2. This is non-negotiable—antibiotics alone will fail if pus is present 2, 3. Drainage can be performed with techniques ranging from simple needle instrumentation to formal incision 3, 6. Early drainage prevents progression to complications like osteomyelitis 7.

Reassessment and Escalation

• Re-evaluate after 2 weeks of initial therapy 1, 2
• If no improvement or worsening occurs at 2 weeks, escalate treatment or refer to dermatology/podiatry (not general surgery) 2, 4
• For grade 3 severity (limiting self-care activities) or intolerable grade 2 disease that fails medical management, consider partial nail avulsion 8, 1, 2
• If excessive granulation tissue develops, use silver nitrate chemical cauterization 2, 4

Prevention to Avoid Recurrence

• Trim nails straight across and avoid cutting them too short 1, 2
• Avoid nail biting and trauma to the nail fold 1, 2
• Apply daily emollients to cuticles and periungual tissues to restore the protective barrier 1, 2
• Wear protective gloves during cleaning or activities involving prolonged water/chemical exposure 1, 2
• Keep the area dry, as moisture disrupts the nail barrier 2, 4

Common Pitfalls to Avoid

• Do not reflexively prescribe oral antibiotics for simple erythema and swelling without signs of true infection—most early cases respond to soaks and topical therapy alone 1, 3
• Do not miss an abscess—if fluctuance is present, drainage is mandatory and antibiotics will not suffice 1, 2
• Do not overlook fungal superinfection, especially if the patient has chronic moisture exposure or diabetes; obtain cultures in refractory cases 1, 4
• Do not ignore worsening disease—paronychia can progress to osteomyelitis if inadequately treated, given the anatomic proximity of nail folds to phalanges 7