If an abscess or fluctuance is present, immediate treatment includes drainage of the affected area. To perform this procedure, a no. 15 scalpel blade is inserted between the nail plate and the cuticle. The nail fold is then gently massaged to aid in drainage. An incision does not need to be made through the nail fold. Cultures should be obtained in recurrent or chronic cases. Drainage should be followed with warm tap water soaks for 10 to 15 minutes three times a day for one to two days in acute cases. In chronic cases, the area should be kept as dry as possible. In mild acute cases, topical antibiotics like mupirocin (Bactroban) can be applied twice a day for seven days. In more severe acute cases, oral antibiotics such as cephalexin or dicloxacillin (250 mg po qid for 10 days) should be started until culture results and sensitivities have returned.

In chronic paronychia, the hands should be kept dry. Avoiding prolonged water exposure is imperative. In occupations where this is not feasible, such as bar tending, janitorial services, or dish washing, the patient should wear a pair of thin cotton gloves underneath rubber or vinyl gloves. The cotton gloves should be changed frequently as sweating can lead to maceration and further contribute to the problem. All manicuring should be stopped. Drying agents are the treatment of choice. A 2% to 4% thymol in absolute alcohol can be compounded by a pharmacist and applied to the area four times a day. Topical antifungal solutions, such as clotrimazole solution, can be used twice a day as well. Acute flares should be treated like acute paronychia with drainage and antibiotics. Occasionally, severe or recalcitrant candidal paronychia may require oral antifungal therapy with fluconazole or itraconazole. Such cases should be referred to a dermatologist.

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