Paronychia: Treatment

Classification

Acute Paronychia Treatment

Stage 1 - Early Cellulitis (No Abscess)

• Warm soaks 3x/day
• Topical antibiotics (e.g., mupirocin/Bactroban) with or without topical corticosteroids
• If significant cellulitis is present: oral broad-spectrum antistaphylococcal antibiotic - cephalosporin or semi-synthetic penicillin (e.g., dicloxacillin, cefalexin)
• Incision has no value at the purely cellulitic stage

Stage 2 - Frank Abscess

1. Digital block for anesthesia (not always required for small lesions)
2. Elevation of the eponychial fold away from the nail matrix - this alone often allows adequate drainage, as paronychia is a collection in the potential space between cuticle and nail, not a true cutaneous abscess
3. A simple nick through the most translucent area of the abscess is usually sufficient
4. If the abscess is unilateral, incise at that corner, angling the knife away from the nail to avoid cutting the nail bed (which causes ridging)
5. If abscess is under one corner of the nail root, remove that corner of nail
6. If infection has migrated to the opposite side and under the nail: make a second incision, reflect the skin proximally, and excise the proximal one-third of the nail
7. Pack loosely with iodoform gauze for 48 hours
8. Alternative technique: lift the nail fold with the tip of a 21- or 23-gauge needle - resolved 8/10 cases with no anesthesia needed

• Marked surrounding cellulitis
• Immunocompromised patients
• Diabetics
• Suspicion of CA-MRSA (add TMP-SMX or doxycycline)

Stage 3 - Subungual Abscess

• Full partial or complete nail avulsion is required
• Wound packing + oral antibiotics usually indicated here

Chronic Paronychia Treatment

• Protective measures: cotton-lined rubber gloves to avoid contact with water and irritants
• Topical steroids (for the inflammatory component)
• Topical antimicrobials (including antifungals if Candida is suspected)
• Address the underlying cause (occupational exposure, nail cosmetics, frequent wetting)

Herpetic Whitlow (Important Differential)

• Clear vesicle formation (rather than frank pus)
• May have lymphangitis and lymphadenopathy
• Confirm with viral culture, Tzanck smear, or serum antibody titers
• Self-limiting - usually resolves without intervention
• Do NOT incise - incision worsens outcome and risks spread
• Acyclovir (oral) can shorten duration, especially in immunocompromised patients

Causative Organisms

Summary Algorithm

Paronychia
├── No abscess (cellulitis only)
│   └── Warm soaks + topical abx ± topical steroids
│       └── If significant cellulitis: oral antistaphylococcal abx
├── Abscess present
│   └── Drain (lift eponychial fold or small nick)
│       ├── Confined to one side: unilateral incision
│       ├── Under nail root corner: remove that nail corner
│       └── Bilateral / subungual: reflect flap + excise proximal 1/3 nail
│           └── Antibiotics only if: cellulitis, immunocompromised, MRSA risk
└── Chronic paronychia
    └── Protective measures + topical steroids + topical antifungals/antibiotics