What Clinicians Can Do When Patients Present with Paronychia

When a patient presents with a red, swollen, and painful area close to the nail bed, it may be more than just a cut.

Paronychia—an inflammatory reaction caused by bacterial invasion of the proximal or lateral nail fold—is the most common hand infection in the United States. The painful lesion usually occurs on one side of the nail, but if left untreated, it can become a “run-around” infection that spreads to the entire peri-nail area. It can also develop on toes.

Patients may report a traumatic injury, hangnails, or cracks around the nail preceding paronychia. Nail-biters are at increased risk for a different infection—Eikenella corrodens—in the mouth.

Paronychia can present in 2 forms: an acute infection that’s usually bacterial, or a chronic condition that’s most often fungal. In most cases, retail clinicians only need to conduct a physical exam to make the diagnosis. If there’s any question about the causative organism, cultures may be needed.

In the case of acute infection, the usual culprit isStaphylococcus aureus,but occasionally,Streptococcus pyogenesmay be involved. Paronychia with an abscess would require incision and drainage.

For cases of uncomplicated paronychia with no abscess, clinicians can advise patients to soak the infection in warm water, aluminum acetate (Burow solution), vinegar, chlorhexidine, or povidone-iodine 3 to 4 times a day. For more severe paronychia, clinicians can prescribe oral antibiotics with gram-positive coverage, such as antistaph penicillins like amoxicillin/clavulanate. A first-generation cephalosporin, such as cotrimoxazole or clindamycin, can address infection and is often given in conjunction with topical steroids (betamethsone). Patients should also continue with soaks.

Treatment options for chronic paronychia include long-course oral antifungals, such as ketoconazole, itraconazole, or fluconazole, along with appropriate monitoring.

In both types of paronychia, patient education can speed resolution and prevent recurrence. In all cases, OTC analgesics can help relieve pain.

In addition to complete treatment adherence, clinicians should remind patients to do the following:

â–ºKeep their fingers out of their mouths.

â–ºAvoid trauma to their digits and irritants.

â–ºNever cut the nail fold or cuticle.

â–ºKeep their digits dry (wear cotton-lined gloves or boots).

â–ºMoisturize if the skin becomes dry.