What is the appropriate management for an 8‑month‑old infant with paronychia of the hallux toe?

Management of Paronychia in an 8-Month-Old Infant

For an 8-month-old infant with paronychia of the hallux toe, initiate treatment with warm water soaks and topical povidone-iodine 2% twice daily, combined with a topical antibiotic (such as bacitracin) and a medium-to-high potency topical corticosteroid if there is no purulent drainage. 1, 2

Initial Assessment and Severity Grading

Examine the affected toe to determine the severity and presence of complications:

• Grade 1 (mild): Erythema and mild swelling of the nail fold without purulent drainage 1
• Grade 2 (moderate): More pronounced inflammation with possible purulent drainage or abscess formation 1
• Grade 3 (severe): Extensive inflammation, significant purulent drainage, or systemic signs 1

Look specifically for signs of abscess formation (fluctuance, pointing), which would mandate surgical drainage regardless of severity grade. 3, 4

Treatment Algorithm by Severity

For Mild Paronychia (Grade 1):

• Warm water soaks 3-4 times daily 2, 3
• Topical povidone-iodine 2% applied twice daily 1, 2
• Topical antibiotic (bacitracin or mupirocin) combined with medium-to-high potency topical corticosteroid twice daily 1
• No oral antibiotics needed at this stage 1, 2

For Moderate Paronychia (Grade 2):

• Continue all topical treatments as above 1
• Add oral antibiotics: cephalexin (25-50 mg/kg/day divided into 3-4 doses) or amoxicillin-clavulanate (20-40 mg/kg/day of amoxicillin component divided twice daily) 1, 2
• Surgical drainage is mandatory if an abscess has formed 1, 4

For Severe Paronychia (Grade 3):

• Obtain bacterial cultures before starting or changing antibiotics 1, 2
• Continue intensive topical treatment plus oral antibiotics 1
• Mandatory surgical drainage if abscess is present 1
• Consider hospitalization if systemic signs are present 3

Critical Antibiotic Considerations

Avoid clindamycin in this age group due to inadequate coverage for some streptococcal species and increasing resistance patterns, particularly relevant given a reported case of clindamycin-resistant Staphylococcus aureus paronychia in an 8-day-old neonate. 2, 5

The most common pathogens are Staphylococcus aureus and Streptococcus species, making beta-lactam antibiotics the preferred choice. 6, 3

Important Clinical Pitfalls to Avoid

• Do not use topical corticosteroids if purulent drainage is present, as this can worsen bacterial infection 1, 2
• Do not prescribe oral antibiotics without adequate drainage if an abscess is present—drainage is the primary treatment 3, 4
• Remember that up to 25% of paronychia cases have secondary bacterial or fungal superinfections, so if initial treatment fails, consider fungal involvement 7, 1

Mandatory Follow-Up Protocol

Reevaluate after 2 weeks of treatment. 1, 8 If there is no improvement or worsening:

• Escalate therapy to the next severity level 1
• Obtain bacterial and fungal cultures if not already done 8, 2
• Consider surgical consultation if conservative management has failed 4

Preventive Measures for Parents

Educate parents on the following to prevent recurrence:

• Keep the infant's toenails straight and not too short when trimming 7, 1
• Apply daily emollients to cuticles and periungual tissues 7, 1
• Ensure comfortable, well-fitting shoes and cotton socks 7, 1
• Keep feet dry and avoid prolonged moisture exposure 1
• Avoid trauma to the nail fold area 7

Special Considerations for Infants

While most guidelines focus on older children and adults, the principles apply to infants with appropriate dose adjustments for oral antibiotics. 3 Neonatal and infant paronychia is rare but has been documented, with bacterial causes being most common. 5 The hallux toe is particularly vulnerable to trauma from footwear or repetitive pressure, making preventive measures especially important. 7, 4