Approach
In acute paronychia, once the diagnosis is made, the treatment is determined by disease severity. Early and/or mild cases with few symptoms and only a small collection of pus can be treated with drainage, drying soaks, and topical antibacterial agents.[3][11] Incision and drainage is only performed if a collection is present. More advanced cases also require systemic antibacterial agents. In both cases, culture and sensitivities should be sent prior to instituting antibacterial treatment, in order to establish if MRSA is present.[1][2] All positive MRSA cultures should be treated with systemic antibiotics according to sensitivity. This will avoid treatment failure due to the possibility of the MRSA being the causative factor for the paronychia.
Acute paronychia (mild bacterial)
Mild acute paronychia, which is less painful and has less periungual tissue involved with no local extension or systemic signs of infection, can be treated with drying soaks (e.g., warm saline, aluminum acetate, chlorhexidine, and povidone-iodine), and a topical antimicrobial.[3][11] Incision and drainage of any pus collection is required.[3][11]
Acute paronychia (severe bacterial)
Any severe or painful acute paronychia, with features such as significant pain, involvement of an extended area of periungual tissue and/or local extension, a fluctuant pus collection, or systemic signs of infection, requires specific systemic antimicrobial therapy based on culture and sensitivity. Appropriate empiric therapy includes a first-generation cephalosporin or an expanded-spectrum penicillin. Clindamycin or erythromycin may be used if the patient is penicillin-allergic. Incision and drainage of any pus collection is required.[3][11] Drying soaks (e.g., warm saline, aluminum acetate, chlorhexidine, and povidone-iodine), may also be used.[3][11]
Acute paronychia (herpetic)
Once this diagnosis is confirmed, treatment with an oral antiviral (e.g., acyclovir, valacyclovir, or famciclovir) can be considered.[12]
Chronic paronychia
The key to treatment of chronic paronychia is understanding the normal nail barrier function and then communicating that to the patient. Water and irritant avoidance regimen is the hallmark of therapy. Steps in treatment are as follows:[2]
Elimination of the cause by avoiding contact irritants and water exposure, as well as physical manipulation and/or trauma to the nail folds
Use of cotton gloves under vinyl gloves for all wet work and exposure to chemicals, acids, alkalis (including cooking many foods), paints, and solvents
Topical corticosteroids for 2 to 3 weeks (class I or II)
Avoiding all nail products (polish, remover, conditioner, hardener) and the nail salon
Using alcohol-based hand cleanser or very little mild soap when washing hands, with complete drying of the hands afterward
Protecting hands from drying and chapping in cold weather
Treatment of any superimposed acute paronychia.
If patients are refractory to treatment, intralesional corticosteroids or excision of the proximal nail fold are second- and third-line possibilities respectively.[1][2] The square flap surgical technique removes fibrotic tissue without complete excision of the proximal and lateral nail fold, thereby reducing nail fold retraction and recovery time.[13]
There is debate regarding the significance and subsequent treatment of secondary colonizing yeast and bacteria. Most nail experts consider their presence almost always a secondary phenomenon. First-line options for treatment, if indicated, are clotrimazole solution or ciclopirox suspension, until the nail fold has normalized.[2][14][15][16] Although rarely necessary, if persistent infection with pseudohyphae is observed on potassium hydroxide or biopsy, an oral antifungal such as fluconazole can be prescribed. There is no need for an oral antibacterial unless there is an acute flare in the setting of chronic paronychia. A green nail may imply Pseudomonas infection, which can be treated with dilute white vinegar soaks.
Retronychia
Nail plate avulsion is curative, but relieving tissue pressure on the nail plate and fixing them with adhesive tape is an option in early cases.[4][9] An oral nonsteroidal anti-inflammatory drug may be prescribed, although this is not necessary in all cases.
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