Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute paronychia

1st line – soaks + topical antibacterial + incision and drainage

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ACUTE
|
acute paronychia
|
mild bacterial infection
1st line – 

soaks + topical antibacterial + incision and drainage

Mild acute paronychia is usually determined by patient symptoms combined with clinical exam. Treatment must be targeted at the bacterial trigger.

Empiric treatment includes incision and drainage of pus collection if present.[3][11]​ The fluid should always be sent for Gram stain, culture, and sensitivity in order to establish if MRSA is present.

Soaks: warm saline, aluminum acetate, chlorhexidine, or povidone-iodine soaks twice a day.[3][11]

Topical antibacterial: mupirocin, bacitracin, or polymyxin B/bacitracin/neomycin if not allergic.

If unresponsive to treatment, imaging (plain film or MRI) should be performed to evaluate for osteomyelitis.[1]

Primary options

bacitracin topical: (500 units/g) apply to the affected area(s) two to three times daily

OR

mupirocin topical: (2%) apply to the affected area(s) two to three times daily

OR

bacitracin/neomycin/polymyxin B topical: apply to the affected area(s) two to three times daily

Consider – oral antibiotic therapy

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ACUTE
|
acute paronychia
|
mild bacterial infection
Consider – 

oral antibiotic therapy

Treatment recommended for SOME patients in selected patient group

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.

1st line – soaks + topical antibacterial + incision and drainage + oral antibiotic therapy

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ACUTE
|
acute paronychia
|
more tissue involved or severe bacterial infection
1st line – 

soaks + topical antibacterial + incision and drainage + oral antibiotic therapy

Empiric treatment includes incision and drainage of pus collection if present.[3][11]​ The fluid should always be sent for Gram stain, culture, and sensitivity in order to establish if MRSA is present.

Soaks: warm saline, aluminum acetate, chlorhexidine, or povidone-iodine soaks twice a day.[3][11]

Topical antibacterial: mupirocin, bacitracin, or polymyxin B/bacitracin/neomycin if not allergic.

First-line oral antibiotics are a first-generation cephalosporin (e.g., cephalexin) or expanded-spectrum penicillin (e.g., dicloxacillin). In penicillin-allergic patients, clindamycin or erythromycin should be prescribed. In all cases of positive MRSA cultures, antibiotics should be prescribed as per sensitivity. This will avoid treatment failure due to the possibility of the MRSA being the causative factor for the paronychia.

If unresponsive to treatment, imaging (plain film or MRI) should be performed to evaluate for osteomyelitis.[1]

Primary options

bacitracin topical: (500 units/g) apply to the affected area(s) two to three times daily

or

mupirocin topical: (2%) apply to the affected area(s) two to three times daily

or

bacitracin/neomycin/polymyxin B topical: apply to the affected area(s) two to three times daily

-- AND --

dicloxacillin: 500 mg orally every 6 hours for 7-14 days

or

cephalexin: 500 mg orally every 6 hours for 7-14 days

Secondary options

bacitracin topical: (500 units/g) apply to the affected area(s) two to three times daily

or

mupirocin topical: (2%) apply to the affected area(s) two to three times daily

or

bacitracin/neomycin/polymyxin B topical: apply to the affected area(s) two to three times daily

-- AND --

clindamycin: 300 mg orally every 6 hours for 7-14 days

or

erythromycin base: 500 mg orally every 6 hours for 7-14 days

1st line – oral antiviral therapy

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ACUTE
|
acute paronychia
|
herpetic infection
1st line – 

oral antiviral therapy

Treatment for herpetic acute paronychia requires a high degree of clinical suspicion and the diagnosis confirmed by Tzanck smear, direct fluorescent antibody, culture, or polymerase chain reaction.

First-line agents: acyclovir, valacyclovir, famciclovir.[12]​​

If unresponsive to treatment, imaging (plain film or MRI) should be performed to evaluate for osteomyelitis.[1]

Primary options

acyclovir: 400 mg orally three times daily for 7-10 days; or 200 mg orally five times daily for 7-10 days

OR

valacyclovir: 1000 mg orally twice daily for 7-10 days

OR

famciclovir: 250 mg orally three times daily for 7-10 days

ONGOING

chronic paronychia

1st line – education + moisture and irritant avoidance + topical corticosteroid

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ONGOING
|
chronic paronychia
1st line – 

education + moisture and irritant avoidance + topical corticosteroid

Patient should be educated that this is a chronic process to which people are predisposed through occupation, habits, or genetics. They should understand the normal nail barrier, the role of the cuticle in protecting the dorsal nail barrier, and the keys to treatment; in particular, that the therapy is mostly passive until the nail reforms its normal barrier.

Hallmarks of treatment are a moisture and irritant avoidance regimen.

Light cotton gloves should be worn under heavy-duty vinyl gloves for all wet work, including peeling fruits and vegetables and handling raw food.

Avoidance of nail cosmetics (polish, polish remover, hardener, conditioner, cuticle treatment) of all kinds is advised.

There should be no manipulation of the nail or cuticle except routine nail plate trimming.

When washing hands, an alcohol-based hand cleanser or very little mild soap should be used and the hands should be completely dried after washing.

The patient should be advised to avoid chemical solvents such as paint thinners, polishes, and paint and to completely avoid the nail salon.

Anti-inflammatory treatment consists of application of topical corticosteroids (class I or II) for 2 to 3 weeks to the nail folds.

If unresponsive to all therapies or atypical, a biopsy is indicated to rule out squamous cell carcinoma or amelanotic melanoma.[1]

Plain film x-ray or MRI should be performed for underlying osseous pathology if suspected.[1]

Primary options

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily for 2-3 weeks

OR

fluocinonide topical: (0.05%) apply sparingly to the affected area(s) twice daily for 2-3 weeks

Consider – treatment of secondary colonization of yeast or bacteria

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ONGOING
|
chronic paronychia
Consider – 

treatment of secondary colonization of yeast or bacteria

Treatment recommended for SOME patients in selected patient group

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 for 5 minutes twice daily.

If unresponsive to all therapies or atypical, a biopsy is indicated to rule out squamous cell carcinoma or amelanotic melanoma.[1]

Plain film x-ray or MRI should be performed for underlying osseous pathology if suspected.[1]

Primary options

clotrimazole topical: (1%) apply to the affected area(s) two to three times daily

OR

ciclopirox topical: (0.77%) apply to the affected area(s) twice daily

Secondary options

fluconazole: 400 mg orally once weekly

2nd line – intralesional corticosteroids

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ONGOING
|
chronic paronychia
2nd line – 

intralesional corticosteroids

This treatment is reserved for treatment-resistant or severe cases, when direct injection of the drug is required for persistent inflammation.

The treatment is given optimally, with a topical anesthetic or cryogen spray, with a 30-gauge needle and injected as a wheal, approximately 0.1 mL per proximal nail fold.

If unresponsive to all therapies or atypical, a biopsy is indicated to rule out squamous cell carcinoma or amelanotic melanoma.[1]

Plain film x-ray or MRI should be performed for underlying osseous pathology if suspected.[1]

Primary options

triamcinolone acetonide: 2.5 to 5 mg/mL (diluted from a 10 mg/mL solution with lidocaine) intralesionally once monthly until improvement, then taper and discontinue

3rd line – surgery

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ONGOING
|
chronic paronychia
3rd line – 

surgery

Excision of proximal nail fold is reserved for those patients with disease resistant to first- and second-line treatments. It is carried out under local anesthesia with minimal morbidity and serves as both diagnostic confirmation and therapy, simply by excising the persistently inflamed tissue.[17]

The square flap technique removes fibrotic tissue without complete excision of the proximal and lateral nail fold, thereby reducing nail fold retraction and recovery time.[13]

Plain film x-ray or MRI should be performed for underlying osseous pathology if suspected.[1]

retronychia

1st line – nail plate avulsion ± nonsteroidal anti-inflammatory drug (NSAID)

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ONGOING
|
retronychia
1st line – 

nail plate avulsion ± nonsteroidal anti-inflammatory drug (NSAID)

Nail plate avulsion is curative, but relieving tissue pressure on the nail plate and fixing with adhesive tape is an option in early cases.[4][9] An oral NSAID may be prescribed, although this is not necessary in all cases.

Primary options

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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