What are the main causes of paronychia. How is acute paronychia different from chronic paronychia. What are the most effective treatment options for nail infections. How can paronychia be prevented.

Understanding Paronychia: An Overview of Nail Fold Infections

Paronychia is an inflammatory condition affecting the tissue surrounding fingernails or toenails. This common nail infection can be classified as either acute or chronic, depending on its duration and underlying causes. Understanding the nature of paronychia is crucial for proper diagnosis and treatment.

Paronychia occurs when the protective barrier between the nail and surrounding skin is compromised, allowing pathogens to enter and cause infection. The condition can affect people of all ages and is often associated with certain occupations or habits that increase the risk of nail trauma or exposure to irritants.

Key Facts About Paronychia:

• It can affect both fingernails and toenails
• Acute paronychia develops rapidly, while chronic paronychia persists over time
• The most common cause is direct or indirect trauma to the nail area
• Proper nail care and hygiene are essential for prevention

Acute Paronychia: Causes, Symptoms, and Diagnosis

Acute paronychia is characterized by a sudden onset of symptoms, typically developing within a few days of injury to the nail area. This type of infection is often caused by bacteria, with Staphylococcus aureus being the most common culprit.

What are the primary causes of acute paronychia? The main factor associated with acute paronychia development is trauma to the cuticle or nail fold. This can occur through various means:

• Minor injuries from everyday activities like dishwashing
• Splinter or thorn punctures
• Nail biting (onychophagia)
• Picking at hangnails
• Aggressive manicure procedures
• Application of artificial nails

How does acute paronychia typically present? The clinical manifestations of acute paronychia include:

• Rapid onset of redness (erythema) around the nail
• Swelling (edema) of the proximal and lateral nail folds
• Tenderness or discomfort in the affected area
• Possible pus accumulation if the infection progresses

Diagnosis of acute paronychia is usually based on clinical presentation. In some cases, a digital pressure test may be helpful in the early stages to assess the presence or extent of an abscess.

Chronic Paronychia: A Persistent Nail Fold Inflammation

Chronic paronychia differs from its acute counterpart in several ways. This form of the condition is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. It persists for six weeks or longer and can be a challenging condition to treat effectively.

What factors contribute to chronic paronychia? The development of chronic paronychia is often associated with:

• Repeated exposure to moisture and irritants
• Occupational hazards (e.g., dishwashers, bartenders, cleaners)
• Certain skin conditions (e.g., eczema, psoriasis)
• Immunosuppression
• Diabetes mellitus

How does chronic paronychia manifest clinically? The symptoms of chronic paronychia include:

• Persistent swelling and redness of the nail folds
• Tenderness and discomfort
• Absence of the cuticle
• Nail plate changes (e.g., ridging, discoloration)
• Intermittent acute flare-ups

Treatment Approaches for Acute Paronychia

The management of acute paronychia depends on the severity of the infection and the presence of abscess formation. What are the primary treatment options for acute paronychia?

1. Conservative measures:
   • Warm compresses to promote drainage and reduce inflammation
   • Soaking the affected digit in warm water with Epsom salt
2. Topical treatments:
   • Antibiotics (e.g., mupirocin, bacitracin)
   • Corticosteroids to reduce inflammation
3. Oral antibiotics:
   • Prescribed for more severe infections or those that don’t respond to topical treatment
   • Common choices include dicloxacillin or cephalexin
4. Surgical intervention:
   • Incision and drainage for cases with abscess formation
   • Performed under local anesthesia

Is there evidence supporting one treatment approach over another? Current research suggests that there is no significant difference in outcomes between oral antibiotics and incision and drainage for acute paronychia. The choice of treatment often depends on the severity of the infection and the presence of purulent collection.

Managing Chronic Paronychia: A Multifaceted Approach

Chronic paronychia requires a comprehensive treatment strategy due to its persistent nature and multifactorial etiology. What are the key components of chronic paronychia management?

1. Avoidance of irritants and moisture:
   • Patient education on proper hand hygiene
   • Use of protective gloves for wet work
   • Application of barrier creams
2. Topical treatments:
   • Broad-spectrum antifungal agents (e.g., ciclopirox, ketoconazole)
   • Corticosteroids to reduce inflammation
3. Systemic therapy:
   • Oral antifungals for recalcitrant cases
   • Antibiotics if secondary bacterial infection is present
4. Surgical interventions:
   • En bloc excision of the proximal nail fold for severe cases
   • Eponychial marsupialization, with or without nail removal

Which treatment approach is most effective for chronic paronychia? Studies have shown that topical steroid creams are more effective than systemic antifungals in the treatment of chronic paronychia. However, a combination of topical antifungal and corticosteroid may provide optimal results in many cases.

Preventing Paronychia: Essential Nail Care Tips

Prevention plays a crucial role in managing both acute and chronic paronychia. By adopting proper nail care habits and avoiding potential triggers, individuals can significantly reduce their risk of developing these infections. What are some essential tips for preventing paronychia?

• Avoid trauma to the nails and surrounding skin
• Keep nails clean and dry
• Trim nails straight across and avoid cutting too short
• Wear protective gloves when working with water or chemicals
• Avoid biting nails or picking at cuticles
• Use moisturizer to keep the skin around nails healthy
• Practice good hand hygiene, including proper handwashing techniques
• Be cautious during manicures and avoid aggressive cuticle manipulation

How can individuals with chronic skin conditions reduce their risk of paronychia? For those with underlying conditions like eczema or psoriasis, managing these disorders effectively is crucial. This may involve working closely with a dermatologist to develop an appropriate treatment plan and maintain overall skin health.

Complications and When to Seek Medical Attention

While many cases of paronychia can be managed at home or with minimal medical intervention, some situations require prompt medical attention. What are the potential complications of untreated paronychia?

• Spread of infection to deeper tissues (felon)
• Permanent nail deformity
• Sepsis in severe cases
• Osteomyelitis (bone infection) in rare instances

When should individuals seek medical care for paronychia? It’s important to consult a healthcare provider if:

• Symptoms worsen or fail to improve with home treatment
• There’s significant pain, redness, or swelling
• Pus or fluid accumulation is evident
• Fever or other systemic symptoms develop
• The infection appears to be spreading
• There’s a history of diabetes or immunosuppression

Early intervention can prevent complications and promote faster healing, especially in individuals with underlying health conditions that may compromise their immune response.

Special Considerations: Paronychia in High-Risk Populations

Certain groups of individuals may be at higher risk for developing paronychia or experiencing more severe infections. How does paronychia management differ for these high-risk populations?

Diabetic Patients:

Individuals with diabetes are more susceptible to infections and may experience delayed healing. For diabetic patients with paronychia:

• Closer monitoring is essential
• Early intervention with antibiotics may be necessary
• Proper glucose control is crucial for healing
• Regular foot checks should include nail inspection

Immunocompromised Individuals:

Those with weakened immune systems, such as HIV/AIDS patients or individuals undergoing chemotherapy, require special attention:

• Aggressive treatment may be needed to prevent systemic spread
• Broader-spectrum antibiotics might be prescribed
• Close follow-up is necessary to ensure resolution

Occupational Risk Groups:

Certain professions increase the risk of paronychia due to frequent exposure to water, chemicals, or trauma. For these individuals:

• Preventive measures are crucial (e.g., proper use of protective gloves)
• Regular hand care routines should be emphasized
• Occupational health assessments may be beneficial

How can healthcare providers best manage paronychia in these high-risk groups? A multidisciplinary approach, involving dermatologists, endocrinologists, and occupational health specialists when appropriate, can ensure comprehensive care and reduce the risk of complications.

Emerging Treatments and Future Directions in Paronychia Management

As medical research continues to advance, new approaches to treating paronychia are being explored. What are some promising developments in the management of nail fold infections?

Photodynamic Therapy:

This innovative treatment uses light-activated agents to target pathogens:

• May be effective against both bacterial and fungal infections
• Potentially reduces the need for antibiotics
• Currently under investigation for chronic paronychia

Bioengineered Nail Tissues:

Research into tissue engineering could provide new solutions for severe cases:

• Potential for repairing damaged nail folds
• May help in cases of recurrent chronic paronychia
• Still in early stages of development

Targeted Immunomodulators:

These medications could offer new options for chronic paronychia:

• May help manage underlying inflammatory conditions
• Could provide an alternative to long-term steroid use
• Research is ongoing to determine efficacy and safety

What challenges remain in paronychia research and treatment? Despite advancements, several areas require further investigation:

• Developing more effective treatments for chronic paronychia
• Understanding the complex microbiome of the nail fold
• Improving diagnostic methods for early detection
• Addressing antibiotic resistance in recurrent infections

As research progresses, these emerging treatments and ongoing studies hold promise for improving outcomes and quality of life for individuals affected by paronychia. Healthcare providers should stay informed about these developments to offer the most current and effective care to their patients.

Acute and Chronic Paronychia | AAFP

DIMITRIS RIGOPOULOS, MD, GEORGE LARIOS, MD, MS, STAMATIS GREGORIOU, MD, AND ALEVIZOS ALEVIZOS, MD

Am Fam Physician. 2008;77(3):339-346

A more recent article on paronychia is available.

Patient information: See related handout on chronic paronychia, written by the authors of this article.

Author disclosure: Nothing to disclose.

Paronychia is an inflammation of the folds of tissue surrounding the nail of a toe or finger. Paronychia may be classified as either acute or chronic. The main factor associated with the development of acute paronychia is direct or indirect trauma to the cuticle or nail fold. This enables pathogens to inoculate the nail, resulting in infection. Treatment options for acute paronychia include warm compresses; topical antibiotics, with or without corticosteroids; oral antibiotics; or surgical incision and drainage for more severe cases. Chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. The patient should avoid exposure to contact irritants; treatment of underlying inflammation and infection is recommended, using a combination of a broad-spectrum topical antifungal agent and a corticosteroid. Application of emollient lotions may be beneficial. Topical steroid creams are more effective than systemic antifungals in the treatment of chronic paronychia. In recalcitrant chronic paronychia, en bloc excision of the proximal nail fold is an option. Alternatively, an eponychial marsupialization, with or without nail removal, may be performed.

Paronychia (synonymous with perionychia) is an inflammatory reaction involving the folds of tissue surrounding a fingernail or toenail. The condition is the result of infection and may be classified as acute or chronic. This article discusses the etiology, predisposing factors, clinical manifestation, diagnosis, and treatment of acute and chronic paronychia.

Clinical recommendation	Evidence rating	References
The digital pressure test may be helpful in the early stages of paronychial infection when there is doubt about the presence or extent of an abscess.	C	14
There is no evidence that treatment with oral antibiotics is any better or worse than incision and drainage for acute paronychia.	C	23
Topical steroids are more effective than systemic antifungals in the treatment of chronic paronychia.	B	21
Patients with simple chronic paronychia should be treated with a broad-spectrum topical antifungal agent and should be instructed to avoid contact irritants.	C	22

Nail Structure and Function

The nail is a complex unit composed of five major modified cutaneous structures: the nail matrix, nail plate, nail bed, cuticle (eponychium), and nail folds¹(Figure 1). The cuticle is an outgrowth of the proximal fold and is situated between the skin of the digit and the nail plate, fusing these structures together.² This configuration provides a waterproof seal from external irritants, allergens, and pathogens.

Acute Paronychia

ETIOLOGY AND PREDISPOSING FACTORS

The most common cause of acute paronychia is direct or indirect trauma to the cuticle or nail fold. Such trauma may be relatively minor, resulting from ordinary events, such as dishwashing, an injury from a splinter or thorn, onychophagia (nail biting), biting or picking at a hangnail, finger sucking, an ingrown nail, manicure procedures (trimming or pushing back the cuticles), artificial nail application, or other nail manipulation. ^3–5 Such trauma enables bacterial inoculation of the nail and subsequent infection. The most common causative pathogen is Staphylococcus aureus, although Streptococcus pyogenes, Pseudomonas pyocyanea, and Proteus vulgaris can also cause paronychia.^3,6,7 In patients with exposure to oral flora, other anaerobic gram-negative bacteria may also be involved. Acute paronychia can also develop as a complication of chronic paronychia.⁸ Rarely, acute paronychia occurs as a manifestation of other disorders affecting the digits, such as pemphigus vulgaris.⁹

CLINICAL MANIFESTATIONS

In patients with acute paronychia, only one nail is typically involved.¹⁰ The condition is characterized by rapid onset of erythema, edema, and discomfort or tenderness of the proximal and lateral nail folds,¹¹ usually two to five days after the trauma. Patients with paronychia may initially present with only superficial infection and accumulation of purulent material under the nail fold, as indicated by drainage of pus when the nail fold is compressed^12,13(Figure 2). An untreated infection may evolve into a subungual abscess, with pain and inflammation of the nail matrix.¹¹ As a consequence, transient or permanent dystrophy of the nail plate may occur.¹⁰ Pus formation can proximally separate the nail from its underlying attachment, causing elevation of the nail plate.^10,11 Recurrent acute paronychia may evolve into chronic paronychia.^7,12

DIAGNOSIS

The diagnosis of acute paronychia is based on a history of minor trauma and findings on physical examination of nail folds. The digital pressure test may be helpful in the early stages of infection when there is doubt about the presence or extent of an abscess.¹⁴ The test is performed by having the patient oppose the thumb and affected finger, thereby applying light pressure to the distal volar aspect of the affected digit. The increase in pressure within the nail fold (particularly in the abscess cavity) causes blanching of the overlying skin and clear demarcation of the abscess. In patients with severe infection or abscess, a specimen should be obtained to identify the responsible pathogen and to rule out methicillin-resistant S. aureus (MRSA) infection.¹³

DIFFERENTIAL DIAGNOSIS

Psoriasis and Reiter syndrome may also involve the proximal nail fold and can mimic acute paronychia.¹⁰ Recurrent acute paronychia should raise suspicion for herpetic whitlow, which typically occurs in health care professionals as a result of topical inoculation.¹² This condition may also affect apparently healthy children after a primary oral herpes infection. Herpetic whitlow appears as single or grouped blisters with a honeycomb appearance close to the nail.⁸ Diagnosis can be confirmed by Tzanck testing or viral culture. Incision and drainage is contraindicated in patients with herpetic whitlow. Suppressive therapy with a seven-to 10-day course of acyclovir 5% ointment or cream (Zovirax) or an oral antiviral agent such as acyclovir, famciclovir (Famvir), or valacyclovir (Valtrex) has been proposed, but evidence from clinical trials is lacking. ¹⁵

MEDICAL TREATMENT

Treatment of acute paronychia is determined by the degree of inflammation.¹² If an abscess has not formed, the use of warm water compresses and soaking the affected digit in Burow’s solution (i.e., aluminum acetate)¹⁰ or vinegar may be effective.^5,11 Acetaminophen or a nonsteroidal anti-inflammatory drug should be considered for symptomatic relief. Mild cases may be treated with an antibiotic cream (e.g., mupirocin [Bactroban], gentamicin, bacitracin/neomycin/polymyxin B [Neosporin]) alone or in combination with a topical corticosteroid. The combination of topical antibiotic and corticosteroid such as betamethasone (Diprolene) is safe and effective for treatment of uncomplicated acute bacterial paronychia and seems to offer advantages compared with topical antibiotics alone.⁷

For persistent lesions, oral antistaphylococcal antibiotic therapy should be used in conjunction with warm soaks.^11,16,17 Patients with exposure to oral flora via finger sucking or hangnail biting should be treated against anaerobes with a broad-spectrum oral antibiotic (e. g., amoxicillin/clavulanate [Augmentin], clindamycin [Cleocin]) because of possible S. aureus and Bacteroides resistance to penicillin and ampicillin.^3,11,17,18 Medications commonly used in the treatment of acute paronychia are listed in Table 1.^{3,10–13,17–22}

Drug	Typical dosage		Comments
Antibiotics (oral)
Amoxicillin/clavulanate (Augmentin)*	500 mg/125 mg orally three times daily for seven days		Dosage adjustment may be necessary in patients with renal impairment; cross-sensitivity documented with cephalosporins; diarrhea may occur
		or
	875 mg/125 mg orally twice daily for seven days
Clindamycin (Cleocin)*	150 to 450 mg orally three or four times daily (not to exceed 1. 8 g daily) for seven days		Adjust dosage in patients with severe hepatic dysfunction; associated with severe and possibly fatal colitis; inform patient to report severe diarrhea immediately
Trimethoprim/sulfamethoxazole (TMP/SMX; Bactrim, Septra)*	160 mg/800 mg orally twice daily for seven days		High doses may cause bone marrow depression; discontinue therapy if significant hematologic changes occur; caution in folate or glucose-6-phosphate dehydrogenase deficiency
Antibiotics (topical)
Bacitracin/neomycin/polymyxin B ointment (Neosporin)	Three times daily for five to 10 days		Overgrowth of nonsusceptible organisms with prolonged use
Gentamicin ointment	Three or four times daily for five to 10 days		—
Mupirocin ointment (Bactroban)	Two to four times daily for five to 10 days		Avoid contact with eyes; may irritate mucous membranes; resistance may result with prolonged use
Antifungal agents (oral)
Fluconazole (Diflucan)	100 mg orally once daily for seven to 14 days		Hepatotoxicity and QT prolongation may occur
Itraconazole (Sporanox)	200 mg orally twice daily for seven days		Antacids may reduce absorption; edema may occur with coadministration of calcium channel blockers; rhabdomyolysis may occur with coadministration of statins; inhibition of cytochrome P450 hepatic enzymes may cause increased levels of many drugs
Nystatin (Mycostatin) 200,000-unit pastilles	One or two pastilles four times daily for seven to 14 days		Adverse effects include nausea, vomiting, and diarrhea
Antifungal agents (topical)
Ciclopirox topical suspension (Loprox TS)	Twice daily until clinical resolution (one month maximum)		Avoid contact with eyes and mucous membranes
Clotrimazole cream (Lotrimin)	Three times daily until clinical resolution (one month maximum)		Avoid contact with eyes; if irritation or sensitivity develops, discontinue use and begin appropriate therapy
Econazole cream (Spectazole)	Three or four times daily until clinical resolution (one month maximum)		Avoid contact with eyes; if irritation or sensitivity develops, discontinue use and begin appropriate therapy
Ketoconazole cream (Nizoral; brand no longer available in the United States)	Once or twice daily until clinical resolution (one month maximum)		Avoid contact with eyes; if irritation or sensitivity develops, discontinue use and begin appropriate therapy
Nystatin cream	Three times daily until clinical resolution (one month maximum)		Avoid contact with eyes; if irritation or sensitivity develops, discontinue use and begin appropriate therapy
Antiviral agents for herpetic whitlow
Acyclovir (Zovirax) †	200 mg orally five times daily for 10 days		Nausea, vomiting, rash, deposition in renal tubules, and central nervous system symptoms may occur
Famciclovir (Famvir)†	250 mg orally twice daily for 10 days		Dosage adjustment recommended in patients with renal impairment
Valacyclovir (Valtrex)†	500 mg orally twice daily for 10 days		Associated with onset of hemolytic uremic syndrome
Corticosteroids (topical)
Betamethasone 0. 05% cream (Diprolene)	Twice daily for one to two weeks		If infection develops and is not responsive to antibiotic treatment, discontinue use until infection is controlled
Betamethasone valerate 0.1% solution or lotion (Beta-Val)	Once or twice daily for one to two weeks		Prolonged therapy over large body surface areas may suppress adrenal function; if infection develops, discontinue use until infection is controlled
Combination antifungal agent and corticosteroid
Nystatin and triamcinolone cream (Mytrex; brand no longer available in the United States)	Two or three times daily until the cuticle has regrown		Check precautions for both components

SURGICAL TREATMENT

Although surgical intervention for paronychia is generally recommended when an abscess is present, no studies have compared the use of oral antibiotics with incision and drainage. ²³ Superficial infections can be easily drained with a size 11 scalpel or a comedone extractor.¹² Pain is quickly relieved after drainage.¹⁷ Another simple technique to drain a paronychial abscess involves lifting the nail fold with the tip of a 21- or 23-gauge needle, followed immediately by passive oozing of pus from the nail bed; this technique does not require anesthesia or daily dressing.²⁴ If there is no clear response within two days, deep surgical incision under local anesthesia (digital nerve block) may be needed, particularly in children.^8,10,11 The proximal one third of the nail plate can be removed without initial incisional drainage. This technique gives more rapid relief and more sustained drainage, especially in patients with paronychia resulting from an ingrown nail.^8,17,19 Complicated infections can occur in immunosuppressed patients and in patients with diabetes or untreated infections.^11,16 Preventive measures for acute paronychia are described in Table 2. ^{3,10,13,19,20}

Chronic Paronychia

ETIOLOGY AND PREDISPOSING FACTORS

Chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens. ^12,19–21 This disorder can be the result of numerous conditions, such as dish washing, finger sucking, aggressively trimming the cuticles, and frequent contact with chemicals (e.g., mild alkalis, acids).

In chronic paronychia, the cuticle separates from the nail plate, leaving the region between the proximal nail fold and the nail plate vulnerable to infection by bacterial and fungal pathogens.^12,21 Chronic paronychia has been reported in laundry workers, house and office cleaners, food handlers, cooks, dishwashers, bartenders, chefs, fishmongers, confectioners, nurses, and swimmers. In such cases, colonization with Candida albicans or bacteria may occur in the lesion.^19,21

There is some disagreement about the importance and role of Candida in chronic paronychia.^10,21 Although Candida is often isolated in patients with chronic paronychia, this condition is not a type of onychomycosis, but rather a variety of hand dermatitis²¹ caused by environmental exposure (Figure 3). In many cases, Candida disappears when the physiologic barrier is restored.¹²

Chronic paronychia can result as a complication of acute paronychia²⁰ in patients who do not receive appropriate treatment.⁷ Chronic paronychia often occurs in persons with diabetes.³ The use of systemic drugs, such as retinoids and protease inhibitors (e.g., indinavir [Crixivan], lamivudine [Epivir]), may cause chronic paronychia. Indinavir is the most common cause of chronic or recurrent paronychia of the toes or fingers in persons infected with human immunodeficiency virus. The mechanism of indinavir-induced retinoid-like effects is unclear.^25,26 Paronychia has also been reported in patients taking cetuximab (Erbitux), an anti-epidermal growth factor receptor (EGFR) antibody used in the treatment of solid tumors.^27,28

DIAGNOSIS

Diagnosis of chronic paronychia is based on physical examination of the nail folds and a history of continuous immersion of hands in water¹⁰; contact with soap, detergents, or other chemicals; or systemic drug use (retinoids, antiretroviral agents, anti-EGFR antibodies). Clinical manifestations are similar to those of acute paronychia: erythema, tenderness, and swelling, with retraction of the proximal nail fold and absence of the adjacent cuticle. Pus may form below the nail fold.⁸ One or several fingernails are usually affected, typically the thumb and second or third fingers of the dominant hand.¹³ The nail plate becomes thickened and discolored, with pronounced transverse ridges such as Beau’s lines (resulting from inflammation of the nail matrix), and nail loss^8,10,13(Figure 4). Chronic paronychia generally has been present for at least six weeks at the time of diagnosis.^10,12 The condition usually has a prolonged course with recurrent, self-limited episodes of acute exacerbation.¹³

DIFFERENTIAL DIAGNOSIS

Other entities affecting the fingertip, such as squamous cell carcinoma of the nail^29,30(Figure 5), malignant melanoma, and metastases from malignant tumors,³¹ may mimic paronychia. Physicians should consider the possibility of carcinoma when a chronic inflammatory process is unresponsive to treatment.³⁰ Any suspicion for the aforementioned entities should prompt biopsy. Several diseases affecting the digits, such as eczema, psoriasis, and Reiter syndrome, may involve the nail folds.¹⁰

TREATMENT

Treatment of chronic paronychia includes avoiding exposure to contact irritants and appropriate management of underlying inflammation or infection.^12,20 A broad-spectrum topical antifungal agent can be used to treat the condition and prevent recurrence.²² Application of emollient lotions to lubricate the nascent cuticle and the hands is usually beneficial. One randomized controlled trial assigned 45 adults with chronic paronychia to treatment with a systemic antifungal agent (itraconazole [Sporanox] or terbinafine [Lamisil]) or a topical steroid cream (methylprednisolone aceponate [Advantan, not available in the United States]) for three weeks. ²¹ After nine weeks, more patients in the topical steroid group were improved or cured (91 versus 49 percent; P < .01; number needed to treat = 2.4).

The presence or absence of Candida seems to be unrelated to the effectiveness of treatment. Given their lower risks and costs compared with systemic antifungals, topical steroids should be the first-line treatment for patients with chronic paronychia.²¹ Alternatively, topical treatment with a combination of steroid and antifungal agents may also be used in patients with simple chronic paronychia, although data showing the superiority of this treatment to steroid use alone are lacking.¹⁹ Intralesional corticosteroid administration (triamcinolone [Amcort]) may be used in refractory cases.^8,19 Systemic corticosteroids may be used for treatment of inflammation and pain for a limited period in patients with severe paronychia involving several fingernails.

If patients with chronic paronychia do not respond to topical therapy and avoidance of contact with water and irritants, a trial of systemic antifungals may be useful before attempting invasive approaches. Commonly used medications for chronic paronychia are listed in Table 1.^{3,10–13,17–22}

In patients with recalcitrant chronic paronychia, en bloc excision of the proximal nail fold is effective. Simultaneous avulsion of the nail plate (total or partial, restricted to the base of the nail plate) improves surgical outcomes.^8,32 Alternatively, an eponychial marsupialization, with or without nail removal, may be performed.³³ This technique involves excision of a semicircular skin section proximal to the nail fold and parallel to the eponychium, expanding to the edge of the nail fold on both sides.³³ Paronychia induced by the EGFR inhibitor cetuximab can be treated with an antibiotic such as doxycycline (Vibramycin).²⁸ In patients with paronychia induced by indinavir, substitution of an alternative antiretroviral regimen that retains lamivudine and other protease inhibitors can resolve retinoid-like manifestations without recurrences. ²⁵

Preventive measures for chronic paronychia are described in Table 2.^{3,10,13,19,20}

PROGNOSIS

Chronic paronychia responds slowly to treatment. Resolution usually takes several weeks or months, but the slow improvement rate should not discourage physicians and patients. In mild to moderate cases, nine weeks of drug treatment usually is effective. In recalcitrant cases, en bloc excision of the proximal nail fold with nail avulsion may result in significant cure rates. Successful treatment outcomes also depend on preventive measures taken by the patient (e.g., having a water barrier in the nail fold). If the patient is not treated, sporadic, self-limiting, painful episodes of acute inflammation should be expected as the result of continuous penetration of various pathogens.

Causes and treatment of an infected nail

Paronychia is a bacterial or fungal skin infection that develops around the nail. Home remedies include soaking in warm water and applying lemon and salt. In some cases, medical treatment may be necessary.

Paronychia can result from biting or chewing the nails, but it is more common when working conditions require the hands to be frequently wet or exposed to chemicals.

Most cases of paronychia are not serious, and there are several effective treatments. This article will discuss the causes and treatments of this infection.

Paronychia is an infection of the surrounding tissue where the nail meets the skin. Onychia is an infection of the nail itself, which causes inflammation of the nail and swelling of the surrounding tissue.

Doctors may also refer to paronychia as candidal paronychias. There is usually a disruption in the barrier between the nail plate and nail fold. This results in infection from the yeast Candida albicans.

Both paronychia and an ingrown toenail can cause pain in the toe area. While they can occur at the same time, they are two distinct issues.

An ingrown toenail is when the nail plate grows into the surrounding skin, causing inflammation and infection. It can cause pain and discomfort, especially if left untreated.

Because the nail breaks the skin, it frequently causes infections, including paronychia.

Ingrown toenails may result from:

• improper nail cutting
• poor foot hygiene
• wearing shoes that are too small and cause pressure on the corners of the toenail
• foot injury
• medications that affect the skin

Some symptoms of paronychia resemble those of different skin infections. Other symptoms directly affect the nail itself.

Paronychia symptoms include:

• swelling, tenderness, and redness around the nail
• pus-filled abscesses
• hardening of the nail
• deformation or damage to the nail
• separation of the nail from the nailbed

Paronychia occurs when the skin around the nail becomes damaged, allowing germs to enter.

Bacteria or fungi can cause the infection, such as Staphylococcus aureus and Streptococcus pyogenes bacteria.

Common causes of skin damage around the nail include:

• biting or chewing the nails
• picking at nails
• manicures
• excessive exposure of the hands to moisture, including frequently sucking the finger
• ingrown nails

Doctors diagnose paronychia by identifying the type of bacteria or fungi causing the infection.

They will obtain a clipping of the nail or take a swab of the infected area and test for the presence of specific bacteria or fungi. Having done this, they can make a diagnosis.

Treatments for paronychia will vary according to the severity and whether it is acute or chronic. Both at-home treatments and medical treatments may help, depending on the diagnosis and severity of the condition.

At-home treatment

A person with mild, acute paronychia can try soaking the affected finger or toe in warm water several times a day. If symptoms do not improve, they should seek further treatment.

Mild paronychia may be treatable with just a lemon and salt.

Individuals claim that a person can cure the infection by cutting a slit in a lemon and sprinkling salt into the hole before placing the affected finger in the lemon for a few minutes. They advise repeating this until the infection goes away. However, there seems to be no scientific evidence to support the idea that this can cure paronychia.

Another home remedy is applying magnesium sulfate paste to the infected area. Individuals claim that this helps with pain management and can ward off the infection. However, there doesn’t appear to be scientific evidence to support this claim either.

Chronic paronychia may require weeks or months of treatment. It is important to keep the hands dry and clean throughout. If a person’s job requires their hands to be wet or exposed to germs, they may need to take time off.

Medical treatment

When a bacterial infection causes acute paronychia, a doctor may recommend an antibiotic, such as dicloxacillin or clindamycin.

If a fungal infection causes chronic paronychia, a doctor will prescribe antifungal medication. These topical medications typically include clotrimazole or ketoconazole.

A doctor may also need to drain any pus from surrounding abscesses. To do this, they perform a procedure referred to as the incision and drainage method. They will provide a local anesthetic, then open the nail fold enough to insert gauze to help drain the pus.

Because many at-home remedies lack scientific support, it is best to consult a medical professional for guidance if you think you have paronychia or another type of toe or toenail infection.

People can treat paronychia at home by minimizing germ exposure and frequently washing the infected area. However, they should only do this if symptoms are mild and the infection has not spread beyond the fingernail.

If symptoms do not improve after a few days or the infection has spread further than the nail, it is important to speak with a doctor.

For severe symptoms, contact a doctor immediately.

People can reduce their risk of developing nail infections by:

• moisturizing after washing the hands
• avoiding biting or chewing the nails
• taking care when cutting the nails
• keeping the hands and nails clean
• avoiding submerging the hands in water for long periods
• avoiding contact with irritants
• keeping the nails short

Some people have a higher risk of developing paronychia, such as:

• people with jobs that require them to have wet hands frequently, including cleaners, fishers, dairy farmers, and bartenders
• people with poor circulation
• people with diabetes
• people with other skin conditions, such as dermatitis
• people with weakened immune systems

In most cases, a doctor can easily diagnose paronychia with a physical examination. They will also consider a person’s medical history and look for risk factors, such as diabetes.

In some cases, a doctor may require a sample of any pus that is present. They can send this to a laboratory for analysis to check whether bacteria or fungi are causing the infection.

Paronychia is a skin infection around a fingernail or toenail. Symptoms include inflammation, swelling, pain, and discomfort. Biting or chewing the nails is a common cause.

Acute paronychia develops quickly and treatment can reduce symptoms rapidly. People can treat mild cases at home. Chronic paronychia has a slower onset, and it can take weeks for treatment to effectively reduce symptoms.

Taking good care of the hands and nails is the best way to prevent paronychia.

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Paronychia is a purulent inflammation of the periungual fold and tissues at the base and sides of the nail. The main reason is infection under the skin as a result of trauma, prolonged exposure to chemicals, or non-compliance with personal hygiene. Also, complications of certain skin, infectious or endocrinological diseases can become the cause of paronychia.

There are several forms of paronychia:

• Tourniolus is the most common form of the disease, characterized by gradually increasing suppuration and an increase in painful symptoms. The form is characteristic of infectious paronychia caused by fungi of the genus Candida or streptococcal infection.
• Erosive and ulcerative forms – develop with syphilis, pemphigus, Duhring’s disease. They are characterized by the appearance of vesicles and ulcers on the skin around the nail, from which “ichor” or pus periodically seeps out. The pathological process often passes to the nail.
• Chronic paronychia is a long-term inflammatory process in which the cuticle may be completely absent, and the nail plate is often thickened or deformed. Chronic paronychia may result from prolonged exposure to chemicals.

Description and symptoms of paronychia

Paronychia begins with swelling and redness of the periungual fold. There is pain and a local increase in temperature. After a while, an abscess and accumulation of pus form.

Further course of the disease leads to spontaneous outpouring of pus from under the nail fold or under the nail plate. In the second case, the nail acquires a yellowish-green color. In some cases, the periungual roller is covered with whitish scales or crusts, ulcers or vesicles.

If left untreated, the disease becomes chronic, in which the nail thickens and deforms. There is a risk of complete loss of the nail plate. Also, the lack of treatment can be fraught with complications such as phlegmon, abscess, tissue necrosis, infection of the tendons, sepsis.

Diagnosis and treatment of paronychia

Only a surgeon can diagnose the disease. In most cases, a simple examination is enough to make a diagnosis. But in order to determine the cause of the disease, it may be necessary to conduct a general blood test, a blood test for sugar and a Wasserman reaction. To exclude a fungal infection, a biopsy of the nail plate is necessary (if the pathological process has affected not only the periungual tissues, but also the nail itself).

Because different causes and forms of paronychia require different treatments, it is recommended that you see a doctor as soon as the first symptoms appear. If treatment is started during the first 3 days from the onset of the disease, it is often possible to do without surgical intervention, using conservative therapy methods.

In case of suppuration, the abscess will need to be opened and drained using outpatient surgery methods. In the clinic of VERBA MEDICAL LLC, this is a minimally invasive operation, using modern ultrasound equipment. The operation can be performed immediately after the diagnosis is confirmed. The next day the patient can return to normal life. But a full recovery can take up to 3 weeks, depending on the causes and degree of the disease, during which observation by a surgeon is required.

To prevent serious complications, make an appointment with the surgeon of the clinic LLC “verba medical” Solodovnik A.V. or Chumak S.A. at the first signs of inflammation or swelling of the periungual tissues.

Paronychia. What is Paronychia?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Paronychia is a dermatological disease with inflammation of the periungual fold caused by trauma, exposure to chemicals or high temperature, followed by infection. Symptoms of this condition are redness, swelling and soreness in the area of ​​​​the roller, possibly with the development of suppuration and abscess. With long-term chronic inflammatory processes, a change in the shape and structure of the nail is possible. Diagnosis of paronychia is usually not difficult and is made on the basis of the results of an examination by a specialist; in some cases, additional research methods are used to clarify the cause of the pathology. Treatment of paronychia is carried out by traditional anti-inflammatory, antibacterial and other means, depending on the etiology of the disease.

• Causes of paronychia
• Classification and symptoms of paronychia
• Paronychia diagnostics
• Treatment and prognosis of paronychia
• Prices for treatment

General information

Paronychia or inflammation of the periungual fold (periungual felon) is an inflammatory lesion (usually acute, less common chronic forms) of the skin tissues surrounding the growth zone of the nails. This is a very common disease, almost every person at least once in his life suffered some form of such inflammation. In persons who, due to professional duties, come into contact with industrial or household chemicals and some other means, paronychia can be considered as an occupational pathology. Often, inflammation acquires a purulent character with the formation of an abscess of the nail fold, while loss of the nail or the transition of the infectious process to deeply located tissues with the development of tendinitis and even purulent fusion of the phalanx may occur. Timely treatment of paronychia is of great importance to prevent the complications of this inflammatory disease.

Paronychia

Causes of paronychia

Modern dermatologists classify paronychia as a polyetiological disease with many forms and varieties of clinical course. The most common form of this condition is due to the penetration of infectious agents into the tissues of the periungual ridge: Staphylococcus aureus, streptococcus, fungi and a number of others. Predisposing factors for infection and the subsequent development of paronychia are trauma, frequent mechanical stress, high temperatures, and contact with certain chemicals. After an infectious agent enters the tissues, it begins to multiply, triggering immune response mechanisms that manifest themselves as simple or purulent inflammation.

This is how the inflammatory process develops in almost 90% of cases of acute paronychia. At the same time, the focus of inflammation of the periungual ridge is mostly located on the side of the palmar surface of the finger, but due to the peculiarities of the anatomical structure of this anatomical structure and complex lymphatic circulation in this area, the main manifestations are localized on the back side. The defeat of the underlying tissues can cause a wide spread of the infectious process to deeply located tissues of the finger and even the hand.

The development of inflammation or abscess can cause not only infection – similar manifestations sometimes accompany other dermatological diseases. In particular, paronychia is isolated due to eczema, psoriasis and some forms of syphilis. As a rule, in these cases, the inflammation is not acute, but chronic, it is accompanied by pronounced changes in the structure and shape of the nail. The reasons for the development of paronychia in eczema or psoriasis have not been thoroughly studied, as, in fact, the etiology of these conditions in general. Another form of inflammation of the nail fold without infection is the professional types of paronychia that occur when working in factories, in contact with household chemicals and other substances. Inflammatory manifestations in such cases are due to the direct damaging effect of certain compounds on the tissues of the periungual ridge.

Classification and symptoms of paronychia

There are many clinical forms of paronychia. The reason for their differences lies in the polyetiology of the disease, which affects the course of the pathology. In addition, differences largely determine the tactics of treating paronychia, the principles of therapy can vary significantly depending on the etiology of inflammation of the nail fold. The modern clinical classification of paronychia used in dermatology includes the following types of pathology:

Pyococcal or purulent paronychia is a form of the disease caused by tissue infection with pyogenic microflora, most often staphylococci and streptococci. Occurs quite often. Symptoms of this condition are a sharp swelling and pain (often – a pulsating character). After 2-3 days of redness, an abscess of the nail fold begins to form, due to the accumulation of pus, the nail fold becomes yellowish. Subsequently, the abscess spontaneously erupts or is opened by the surgeon, the manifestations of pyococcal paronychia weaken and gradually disappear. If left untreated, purulent inflammation may spread to other tissues of the finger and hand. In rare cases, there is a metastatic transfer of the pathogen with the development of abscesses in the internal organs.

Ulcerative paronychia – a feature of this type of disease is the development of ulcers on the nail fold. Both pathogenic bacteria and various chemical influences (contact with caustic compounds, components of household chemicals) can act as an etiological factor. Ulcers are quite painful and often become the entrance gate for secondary infection, which leads to the development of purulent paronychia.

Diagnosis of paronychia

It is quite easy to determine the presence of inflammation of the nail fold by examining the patient’s fingers. Swelling and redness are almost always detected, and pain is detected on palpation. The pyococcal form of the disease is characterized by a sharply swollen roller, which may acquire a yellow tint due to the accumulation of pus. Additional diagnostic methods help to more accurately establish the form of paronychia. To make a diagnosis, an anamnesis is taken, microbiological studies are prescribed, in some cases a general dermatological examination (to detect eczema or psoriasis) and serological tests (to determine syphilis) are used.

When questioning and clarifying the anamnesis of a patient with paronychia, it is possible to detect professional forms of this disease – the pathology often affects bakers, laundry workers and workers in chemical enterprises. The identification of comorbidities (eczema, psoriasis, syphilis) in the patient’s history indicates their role in the development of paronychia, especially in the characteristic clinical picture of the corresponding disease. In the presence of purulent or serous secretions, a microbiological examination (microscopy, inoculation on selective nutrient media) is performed to more accurately identify the pathogen.

Treatment and prognosis of paronychia

Treatment of paronychia is largely determined by the causes that provoked this disease. In pathology caused by infection of the nail fold, local antiseptics and ichthyol ointment are used. With the purulent nature of inflammation and the development of an abscess, surgical opening and drainage are performed, and antibiotic therapy is prescribed. For signs of candidamicotic paronychia, local forms of antifungal drugs (eg, clotrimazole) are used. If the inflammation of the nail fold is caused by exposure to some chemical compound, the patient is advised to limit contact with an aggressive substance or wear protective gloves. With paronychia due to eczema, psoriasis or syphilis, in addition to the general therapy of the underlying disease, corticosteroid ointments and ultraviolet irradiation of the affected areas are used.