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.

Acute and Chronic Paronychia | AAFP

JEFFREY C. LEGGIT, MD

Am Fam Physician. 2017;96(1):44-51

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

Author disclosure: No relevant financial affiliations.

Paronychia is inflammation of the fingers or toes in one or more of the three nail folds. Acute paronychia is caused by polymicrobial infections after the protective nail barrier has been breached. Treatment consists of warm soaks with or without Burow solution or 1% acetic acid. Topical antibiotics should be used with or without topical steroids when simple soaks do not relieve the inflammation. The presence of an abscess should be determined, which mandates drainage. There are a variety of options for drainage, ranging from instrumentation with a hypodermic needle to a wide incision with a scalpel. Oral antibiotics are usually not needed if adequate drainage is achieved unless the patient is immunocompromised or a severe infection is present. Therapy is based on the most likely pathogens and local resistance patterns. Chronic paronychia is characterized by symptoms of at least six weeks’ duration and represents an irritant dermatitis to the breached nail barrier. Common irritants include acids, alkalis, and other chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, and swimmers. Treatment is aimed at stopping the source of irritation while treating the inflammation with topical steroids or calcineurin inhibitors. More aggressive techniques may be required to restore the protective nail barrier. Treatment may take weeks to months. Patient education is paramount to reduce the recurrence of acute and chronic paronychia.

Paronychia is defined as inflammation of the fingers or toes in one or more of the three nail folds. The condition can be acute or chronic, with chronic paronychia being present for longer than six weeks. Although both result from loss of the normal nail-protective architecture, their etiologies are different, thus their treatments differ. Infections are responsible for acute cases, whereas irritants cause most chronic cases.

Clinical recommendation	Evidence rating	References
Ultrasonography can be used to determine the presence of an abscess or cellulitis when it is not clinically evident.	C	10–12
The addition of topical steroids to topical antibiotics decreases the time to symptom resolution in acute paronychia.	B	19
Oral antibiotics are not needed when an abscess has been appropriately drained.	C	25, 26
Chronic paronychia is treated by topical anti-inflammatory agents and avoidance of irritants. Antifungals should not be used.	C	1, 29

Acute paronychia usually involves only one digit at a time; more widespread disease warrants a broader investigation for systemic issues (Table 1). ^1,2 Chronic paronychia typically involves multiple digits. Paronychia usually affects the fingernails, whereas ingrown nails (onychocryptosis) are more common with the toenails. Although ingrown toenails resulting from abnormal growth of the nail plate into the nail fold are a cause of acute paronychia, this article will not address the management of ingrown nails, which has been addressed previously in American Family Physician.³ Although prevalence data are lacking, acute paronychia is one of the most common hand infections in the United States. It is three times more common in women, possibly because of more nail manipulation in this population.⁴

Anatomy

The relevant anatomy includes the nail bed, nail plate, and perionychium¹(Figure 1⁵). The nail bed is composed of a germinal matrix, which can be seen as the lunula, the crescent-shaped white area at the most proximal portion of the nail. The germinal matrix is responsible for new nail growth. The more distal portion of the nail bed is made by the flesh-colored sterile matrix, which is responsible for strengthening the nail plate. The perionychium comprises the three nail folds (two lateral and one proximal) and the nearby nail bed.

The proximal nail fold is unique compared with the two lateral folds. The nail plate itself arises from a mild depression in the proximal nail fold. The nail divides the proximal nail fold into two parts, the dorsal roof and the ventral floor, both of which contain germinal matrices. The eponychium (also called the cuticle), an outgrowth of the proximal nail fold, forms a watertight barrier between the nail plate and the skin, protecting the underlying skin from pathogens and irritants.²

Acute Paronychia

DIAGNOSIS

Acute paronychia is the result of a disruption of the protective barrier of the nail folds. Once this barrier is breached, various pathogens can create inflammation and infection. Table 2 lists the most common risks of nail fold disruption.⁵ Patients typically present with rapid onset of an acute, inflamed nail fold and accompanying pain (Figure 2). The diagnosis is clinical, but imaging may be useful if a deeper infection is suspected.⁶ It is not helpful to send expressed fluid for culture because the results are often nondiagnostic and do not affect management.^7,8 In a study of patients requiring hospitalization for paronychia who underwent incision and drainage with culture, only 4% of the cultures were positive, with a polymicrobial predominance of bacteria.⁶ The most common pathogens isolated are listed in Table 3.^2,6Pseudomonas infections can be identified by a greenish discoloration in the nail bed⁹(Figure 3). Other diagnostic tools such as radiography or laboratory tests are needed only if the clinical presentation is atypical. The differential diagnosis of acute paronychia includes a felon, which is an infection in the finger pad or pulp.^1,2 Although acute paronychia can lead to felons, they are differentiated by the site of the infection.

Risk factors

Accidental trauma

Artificial nails

Manicures

Manipulating a hangnail (i.e., shred of eponychium)

Occupational trauma (e.g., bartenders, housekeepers, dishwashers, laundry workers)

Onychocryptosis (i.e., ingrown nails)

Onychophagia (nail biting)

Recommendations to prevent recurrent paronychia*

Apply moisturizing lotion after hand washing.

Avoid chronic prolonged exposure to contact irritants and moisture (including detergent and soap).

Avoid nail trauma, biting, picking, and manipulation, and finger sucking.

Avoid trimming cuticles or using cuticle removers.

Improve glycemic control in patients with diabetes mellitus.

Keep affected areas clean and dry.

Keep nails short.

Provide adequate patient education.

Use rubber gloves, preferably with inner cotton glove or cotton liners when exposed to moisture and/or irritants.

If there is uncertainty about the presence of an abscess, ultrasonography can be performed. Fluid collection indicates an abscess, whereas a subcutaneous cobblestone appearance indicates cellulitis.^10–12 The digital pressure test has been suggested as an alternative to confirm the presence of an abscess. To perform the test, the patient opposes the thumb and affected finger, applying light pressure to the distal volar aspect of the affected digit. The pressure within the nail fold causes blanching of the overlying skin and clear demarcation of an abscess, if present.¹³

TREATMENT

Treatment of acute paronychia is based on the severity of inflammation and the presence of an abscess. If only mild inflammation is present and there is no overt cellulitis, treatment consists of warm soaks, topical antibiotics with or without topical steroids, or a combination of topical therapies. Warm soaks have been advocated to assist with spontaneous drainage.¹⁴ Although they have not been extensively studied, Burow solution (aluminum acetate solution) and vinegar (acetic acid) combined with warm soaks have been used for years as a topical treatment. Burow solution has astringent and antimicrobial properties and has been shown to help with soft tissue infections.¹⁵ Similarly, 1% acetic acid has been found effective for treating multidrug-resistant pseudomonal wound infections because of its antimicrobial properties.¹⁶ Soaking can lead to desquamation, which is normal.¹⁷ Topical antibiotics for paronychia include mupirocin (Bactroban), gentamicin, or a topical fluoroquinolone if pseudomonal infection is suspected. Neomycin-containing compounds are discouraged because of the risk of allergic reaction (approximately 10%).¹⁸ The addition of topical steroids decreases the time to symptom resolution without additional risks.¹⁹

If an abscess is present, it should be opened to facilitate drainage. Soaking combined with other topical therapies can be tried, but if no improvement is noted after two to three days or if symptoms are severe, the abscess must be mechanically drained⁵(Figure 4⁴). No randomized controlled trials have compared methods of drainage, and treatment should be individualized according to the clinical situation and skill of the physician. An instrument such as a nail elevator or hypodermic needle can be inserted at the junction of the affected nail fold and nail.²⁰

Once the abscess has been opened, spontaneous drainage should occur. If it does not, the digit can be massaged to express the fluid from the opening. If massage is unsuccessful, a scalpel can be used to create a larger opening at the same nail fold–nail junction. If spontaneous drainage still does not occur, the scalpel can be rotated with the sharp side down to avoid cutting the skin fold. Spontaneous drainage should ensue, but if it does not, the area should be massaged to facilitate drainage. The skin directly over the abscess can be opened with a needle or scalpel if elevation of the nail fold and nail does not result in drainage. Ultrasonography can be performed if there is uncertainty about whether an abscess exists or if difficulty is encountered with abscess drainage. ^10,11

Anesthesia is generally not needed when using a needle for drainage.²⁰ More extensive procedures will likely require anesthesia. Applying ice packs or vapocoolant spray may suffice. If not, infiltrative or digital block anesthesia should be administered. Infiltrative anesthesia or a wing block is faster than a digital block and has less risk of damaging proximal digital blood vessels and nerves.²¹ A wing block is accomplished by inserting a 30-gauge or smaller needle just proximal to the eponychium and slowly administering anesthetic until the skin blanches (see https://www.youtube.com/watch?v=47qHTmEEHdg). The needle is then directed to each lateral nail fold, and another small bolus of anesthetic is delivered until the skin blanches. Significant resistance is often encountered because of the small needle gauge and tight space. The needle is then removed and reinserted distally along each lateral nail fold until the entire dorsal nail tip is anesthetized. The anesthetic must be injected slowly to avoid painful tissue distension. The pulp and finger pad should not be injected. Several anesthetic agents are available, but 1% to 2% lidocaine is most common. Lidocaine with epinephrine is safe to use in patients with no risk factors for vasospastic disease (e.g., peripheral vascular disease, Raynaud phenomenon). The use of epinephrine allows for a nearly bloodless field without the use of a tourniquet and prolongs the effect of the anesthesia. Buffering and warming the anesthetic aids in patient comfort.²²

A wider incision may be needed if the infection extends around the nail. If the entire eponychium is involved, the nail plate can be removed or the Swiss roll technique (reflection of the proximal nail fold) can be performed.²³ The Swiss roll technique involves parallel incisions from the eponychium just distal to the distal interphalangeal joint (see Figure 78-4 at http://musculoskeletalkey.com/hand-infections). The tissue is folded over a small piece of non-adherent gauze and sutured to the digit on each side. The exposed nail bed is thoroughly irrigated and dressed with non-adherent gauze, then reevaluated in 48 hours. If no signs of infection are present, the sutures can be removed and the flap of skin returned and left to heal by secondary intention.

Antibiotics are generally not needed after successful drainage.²⁴ Prospective studies have shown that the addition of systemic antibiotics does not improve cure rates after incision and drainage of cutaneous abscesses, even in those due to methicillin-resistant Staphylococcus aureus,^25,26 which is more common in athletes, children, prisoners, military recruits, residents of long-term care facilities, injection drug users, and those with previous infections.²⁷ Post-drainage soaking with or without Burow solution or 1% acetic acid is generally recommended two or three times per day for two to three days, except after undergoing the Swiss roll technique. The addition of a topical antibiotic and/or steroids can be considered, but there are no evidence-based recommendations to guide this decision.

The use of oral antibiotics should be limited.^7,8 Patients with overt cellulitis and possibly those who are immunocompromised or severely ill may warrant oral antibiotics.²⁵ When they are required, therapy should be directed against the most likely pathogens. If there are risk factors for oral pathogens, such as thumb-sucking or nail biting, medications with adequate anaerobic coverage should be used. Table 3 lists common pathogens and suggested antibiotic options,^2,6 but local community resistance patterns should be considered when choosing specific agents.²⁷

Recurrent acute paronychia can progress to chronic paronychia. Therefore, patients should be counseled to avoid trauma to the nail folds. Systemic diseases such as psoriasis and eczema can cause acute paronychia; in these cases, treatment should be directed at the underlying cause.

Chronic Paronychia

DIAGNOSIS

Chronic paronychia results from irritant dermatitis rather than an infection.² Common irritants include acids, alkalis, or other chemicals commonly used by housekeepers, dishwashers, bartenders, laundry workers, florists, bakers, and swimmers. Once the protective nail barrier is disrupted, repeated exposure to irritants may result in chronic inflammation. Chronic paronychia is diagnosed clinically based on symptom duration of at least six weeks, a positive exposure history, and clinical findings consistent with nail dystrophy (Figure 5).⁵ The cuticle may be totally absent, and Beau lines (deep side-to-side grooves in the nail that represent interruption of nail matrix maturation) may be present.²⁸ Multiple digits typically are involved. If only a single digit is affected, the possibility of malignancy, such as squamous cell cancer, must be considered (Figure 6).⁵ The presence of pus and redness may indicate an acute exacerbation of a chronic process.

Fungal infections are thought to represent colonization, not a true pathogen, so antifungals are generally not used to treat chronic paronychia.²⁹ Several classes of medications can cause chronic paronychia: retinoids, protease inhibitors (4% of users), antiepidermal growth factor receptor antibodies (17% of users), and several classes of chemotherapeutic agents (35% of users).^30–32 The effect can be immediate or delayed up to 12 months.

TREATMENT

Treatment of chronic paronychia consists of stopping the source of irritation, controlling inflammation, and restoring the natural protective barrier.¹ Topical anti-inflammatory agents, steroids, or calcineurin inhibitors are the mainstay of therapy.³³ In a randomized, unblinded, comparative study, tacrolimus 0.1% (Protopic) was more effective than betamethasone 17-valerate 0.1%.³³ In severe or refractory cases, more aggressive treatments may be required to stop the inflammation and restore the barrier. If the Swiss roll technique is used, the nail bed will need to be exposed for a longer duration (seven to 14 days) than for acute cases (two to three days).²³

If a medication is the cause, the physician and patient must decide whether the adverse effects are acceptable for the therapeutic effect of the drug. Discontinuing the medication should reverse the process and allow healing. Doxycycline has been found effective for treatment of paronychia caused by antiepidermal growth factor receptor antibodies.⁵ A case report describes successful treatment with twice-daily application of a 1% solution of povidone/iodine in dimethyl sulfoxide until symptom resolution in patients with chemotherapy-induced chronic paronychia.³⁴ Zinc deficiency is known to cause nail plate abnormalities and chronic paronychia; treatment with 20 mg of supplemental zinc per day is helpful.³⁵ It is important to inform the patient that the process can take weeks to months to restore the natural barrier. Effective strategies to avoid offending irritants are listed in Table 2.⁵

Data Sources: A PubMed search was completed using the key terms paronychia and nail disorders. The search included systematic and clinical reviews, meta-analyses, reviews of clinical trials and other primary sources, and evidence-based guidelines. Also searched were the Cochrane database, the National Institute for Health and Care Excellence guidelines, the Choosing Wisely Campaign, Essential Evidence Plus, and UpToDate. References from these sources were consulted to clarify statements made in publications. Search dates: December 1, 2015, through January 28, 2017.

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of Defense or the U.S. government.

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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.