eMedicine Specialties > Dermatology > Nails

Paronychia: Treatment & Medication

Author: Steve Lee, MD, Physician in Plastic, Reconstructive, and Hand Surgery, Plastic Surgery, PLLC
Coauthor(s): Allison Vidimos, R PH, MD, Consulting Staff, Section of Micrographic Surgery (Mohs) and Oncology, Department of Dermatology, Cleveland Clinic Foundation; Yelena Bogdan, Stony Brook University Health Sciences Center School of Medicine (SUNY)
Contributor Information and Disclosures

Updated: Aug 11, 2009

Treatment

Medical Care

The treatment of choice depends on the extent of the infection. If diagnosed early, acute paronychia without obvious abscess can be treated nonsurgically. If an abscess has developed, incision and drainage must be performed. Surgical debridement may be required if fulminant infection is present.

Herpetic whitlow and paronychia must be distinguished because the treatments are drastically different. Misdiagnosis and mistreatment may do more harm than good. Once herpetic whitlow is ruled out, one must determine whether the paronychia is acute or chronic and then treat it accordingly.²

• Acute paronychia
  • Warm water soaks of the affected finger 3-4 times per day until symptoms resolve are helpful.
  • Oral antibiotics with gram-positive coverage against S aureus, such as amoxicillin and clavulanic acid (Augmentin) or clindamycin (Cleocin), are usually administered concomitantly with warm water soaks.
  • Cleocin and Augmentin also have anaerobic activity; therefore, they are useful in treating patients with paronychia due to oral anaerobes contracted through nail biting or finger sucking.
  • Cleocin should be used instead of Augmentin in patients who are allergic to penicillin.
  • If the paronychia does not resolve or if it progresses to an abscess, it should be drained promptly.
• Chronic paronychia
  • The initial treatment of chronic paronychia consists of the avoidance of inciting factors such as exposure to moist environments or skin irritants. Keeping the affected lesion dry is essential for proper recovery. Choice of footgear may also be considered.
  • Any manipulation of the nail, such as manicuring, finger sucking, or attempting to incise and drain the lesion, should be avoided; these manipulations may lead to secondary bacterial infections.
  • Mild cases of chronic paronychia may be treated with warm soaks.
  • The initial medical treatment consists of the application of topical antifungal agents. Topical miconazole may be used as the initial agent. Oral ketoconazole or fluconazole may be added in more severe cases.
  • Patients with diabetes and those who are immunocompromised need more aggressive treatment because the response to therapy is slower in these patients than in others.
  • In cases induced by retinoids or protease inhibitors, the paronychia usually resolves if the medication is discontinued.

Surgical Care

If paronychia does not resolve despite best medical efforts, surgical intervention may be indicated. Also, if an abscess has developed, incision and drainage must be performed. Surgical debridement may be required if fulminant infection is present.

• Acute paronychia
  • No-incision technique
    • Less advanced paronychial abscesses can be drained simply by gently elevating the eponychial fold from the nail by using a small blunt instrument such as a metal probe or an elevator (see Media Files 2-3). This separation is performed at the junction of the perionychium and the eponychium and extends proximally enough to permit visualization of the proximal nail edge. Then, the proximal third of the nail can be excised with scissors and the pus evacuated.

• This technique does not require an incision into the matrix. Often, no excision of any tissues is made because only blunt dissection and separation are needed to evacuate the pus from the paronychia.
• The wound should be well irrigated with isotonic sodium chloride solution, and plain gauze packing should be inserted under the fold to keep the cavity open and allow drainage.
• The patient should receive oral antibiotics for 5-7 days.
• The packing is removed after 2 days, and warm sodium chloride solution soaks are begun.
• Single- and double-incision techniques
  • If the paronychia is more advanced, it may need to be incised and drained.
  • A digital anesthetic block is usually necessary. If an anesthetic agent is used, it should consist of 1% lidocaine (Xylocaine) with no epinephrine for a ring block. The local injection of the anesthetic agent into the paronychia or the wound is often inadequate and more painful than the administration of drugs of a digital ring block.
  • If the paronychia involves only 1 lateral fold of the finger, a single longitudinal incision should be placed with either a number-11 or a number-15 blade directed away from the nail fold to prevent proximal injury with a subsequent nail growth abnormality. If both lateral folds of the finger are involved, incisions may be made on both sides of the nail, extending proximally to the base of the nail.
  • After the single or double incision is made, the entire eponychial fold is elevated to expose the base of the nail and drain the pus.
  • The proximal third of the nail is removed by using the technique described for the no-incision technique.
  • After the abscess is drained, the pocket should be well irrigated with isotonic sodium chloride solution, packed with plain packing, and dressed.
  • The patient should receive oral antibiotics for 5-7 days.
  • The dressing and packing are removed in approximately 2 days, and the affected finger is treated with warm soaks for 10-15 minutes 3-4 times per day.
• Chronic paronychia
  • The most common surgical technique used to treat chronic paronychia is called eponychial marsupialization.
  • In this technique, the affected digit is first anesthetized with 1% lidocaine (Xylocaine) with no epinephrine by using the digital ring block method.
  • Tourniquet control of the proximal digit is accomplished by using a finger of a latex glove with the distal end cut off.
  • With a No. 15 blade, a crescent-shaped incision is made proximal to the distal edge of the eponychial fold.
  • The distal incision is made approximately 1 mm proximal to the distal edge of the eponychium and along its curve.
  • At its widest end, the proximal incision is approximately 5 mm from the distal incision.
  • The incision should appear symmetric and extend to the edge of the nail fold on each side.
  • All affected tissue within the boundaries of the crescent and extending down to, but not including, the germinal matrix is excised. In effect, this procedure exteriorizes the infected and obstructed nail matrix and allows its drainage.
  • If the nail plate is grossly deformed at the time of surgery, it may be removed.
  • The excised region is packed with plain gauze wick, which is changed every 2-3 days.
  • Epithelialization of the excised defect occurs over the next 2-3 weeks.
  • Nail improvement occurs over the next 6-9 months but may require as long as 12 months to become apparent.

Diet

No change in diet is required.

Activity

Patients with either acute or chronic paronychia should keep affected areas clean and dry, and they should avoid any further trauma or manipulation of the nail.

Medication

The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.

Antibiotics

Therapy must cover all likely pathogens in the context of this clinical setting.

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Amoxicillin and clavulanic acid (Augmentin)

Drug combination used against bacteria resistant to beta-lactam antibiotics. In children > 3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Antifungals

Mechanism of action usually involves inhibiting pathways (enzymes, substrates, transport) necessary for sterol/cell membrane synthesis or altering the permeability of the cell membrane (polyenes) of the fungal cell.

Miconazole (Maximum strength Desenex)

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Increases membrane permeability, causing nutrients to leak out and resulting in fungal cell death. Lotion preferred in intertriginous areas. If cream used, apply sparingly to avoid maceration effects.

Ketoconazole (Nizoral)

Fungistatic activity. Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak and resulting in fungal cell death.

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