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Paronychia

From WikiSM

Other Names

  • Acute Paronychia
  • Chronic Paronychia

Background

  • This page refers to 'Paronychia', defined as inflammation of the fingers or toes in one or more of the three nail folds

History

  • First described by Bartlett in 1937[1]

Epidemiology

  • One of the most common hand infections (need citation)
  • Three times more common in women[2]

Introduction

Illustration of the fingernail anatomy[3]
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Paronychia Case
(A) Acute paronychia presenting as erythema, swelling and pus discharge along the lateral and proximal nail fold. (B) Acute paronychia of the thumb with subungual abscess[4]
Chronic paronychia associated with tuberculosis[4]

General

  • Defined as inflammation involving the lateral and proximal nail folds
  • Can be acute (< 6 weeks) or chronic (>6 weeks)
  • More common in fingernails than toenails

Acute

  • General
    • Typically affects one digit at a time
    • If more widespread or affects more than one finger, consider systemic workup
    • Result of a disruption of the protective barrier of the nail folds, allowing pathogens to infect
  • Common injury in athletes due to
    • Tight fitting shoe gear
    • Trauma
    • Prolonged exposure to moist environments
  • Infectious: Staphylococcus aureus, Streptococcus pyogenes, Klebsiella pneumoniae
  • Non-infectious: Pemphigus vulgaris, pustular psoriasis, reactive arthritis

Chronic

  • General
    • Results from irritant dermatitis (rather than an infection in acute paronychia)
    • Irritant is usually an acid or alkali related to occupation
    • Defined as being present for at least 6 weeks
    • Typically involves multiple digits
    • Closely related to Onychodystrophy
  • Medications can induce[5]
    • Retinoids
    • Protease inhibitors
    • Antiepidermal growth factor receptor antibodies
    • Chemotherapeutic agents

Associated Conditions

Anatomy of the Nail Bed

  • Nail body is composed of densely packed dead keratinocytes
  • Nail body forms at the nail root, which has a matrix of proliferating cells from the stratum basale that enables the nail to grow continuously
  • Lateral nail fold overlaps the nail on the sides, helping to anchor the nail body
  • Eponychium: nail fold that meets the proximal end of the nail body forms the nail cuticle
  • Nailbed has a rich vascular matrix
    • Germinal matrix: proximal, gives rise to the new nail
    • Sterile matrix: distal, adds volume and strength
  • Lanula: thick layer of epithelium over the nail matrix
  • Hyponychium: area beneath the free edge of the nail, furthest from the cuticle
  • Paronychium: soft tissue lateral to the nail bed
  • Perionychium: paronychium plus the nail bed
  • Proximal nail fold (PNF): anatomic transition between the nail bed and the paronychium
  • Nail vest: thin veil of tissue forms at the junction of PNF and eponychium

Risk Factors

  • Local
    • Accidental trauma
    • Artificial nails
    • Manicures
    • Manipulating a hangnail (i.e., shred of eponychium)
    • Onychocryptosis
    • Onychophagia (nail biting)
  • Occupational trauma
    • Bartenders
    • Housekeepers
    • Dishwashers
    • Laundry workers
    • Florists
    • Baker's
    • Swimmers
  • Systemic

Differential Diagnosis

Differential Diagnosis Finger Pain

Differential Diagnosis Foot Pain

Clinical Features

Common presentation of an acute paronychia.

History: Acute

  • Patient will report rapid onset of inflamed nail fold and accompanying pain
  • Typically 2-5 days after onset of symptoms
  • Erythema, edema, pain, tenderness
  • Abscess is frequently present

History: Chronic

  • Symptoms for at least 6 weeks, positive exposure history, nail dystrophy
  • Pain, swelling, erythema, involves more than one fingernail
  • Mild edema and erythema of the proximal and lateral nail folds with loss of the cuticle
  • Abscess is not present

Physical Exam: Physical Exam Hand

  • Acute: erythema, edema, abscess at edge of nail
  • Chronic: cuticle may be absent, multiple digits typically, can see acute on chronic
  • Beau lines: nonspecific nail dystrophy and nail shedding seen in chronic form
  • Green discoloration of nail plate suggests pseudomonas

Special Tests

Evaluation

  • Primarily clinical a clinical diagnosis where laboratory and imaging is not required

Radiographs

Ultrasound

  • Can be used to determine the presence of an abscess when it is not clinically evident
    • Cellulitis: subcutaneous cobblestone appearance
    • Abscess: hypoechoic or mixed echogenic fluid collection

Laboratory

  • Routine culture is not necessary
    • In a study of patients admitted for paronychia, only 4% of cultures were positive[7]
  • Most common bacteria
    • Staphylococcus aureus, followed by streptococci and Pseudomonas

Classification

  • Acute vs Chronic

Management

Medical management of acute paronychia[4]
Treatment options and common pathogens for acute Paronychia[8]
Paronychia Incision and Drainage. A, The area of fluctuance is incised. B, The abscess is decompressed. C, A probe is used to break up any loculations[9]

Acute Paronychia

  • If mild, with no evidence of cellulitis or abscess
    • Warm soaks
    • Topical antibiotics (with or without topical steroids)
  • Topical treatments
    • Burow solution (aluminum acetate solution) and vinegar (acetic acid)
    • Burow solution has astringent and antimicrobial properties, shown to help with soft tissue infections[10]
    • 1% Acetic Acid effective for treating multidrug-resistant pseudomonal wound infections[11]
  • Topical antibiotics
    • Mupirocin (Bactroban)
    • Gentamicin
    • Topical fluoroquinolone (if pseudomonal infection is suspected)
    • Neomycin-containing compounds are discouraged because of the 10% risk of allergic reaction[12]
  • Oral Antibiotics
    • Indicated in severe or recurrent cases
    • See table of common pathogens and treatment
    • Consider Augmentin BID x 7 days OR Clindamycin 150-450mg TID or QID x 7 days OR TMP-SMX DS 1-2 tab PO BID x 7 days
  • Topical Steroids
    • When added to topical antibiotics, decreases the time to symptom resolution in acute paronychia[13]
  • Toenail paronychia
    • Usually associated with ingrowing nail or retronychia, which need to be addressed

Chronic Paronychia

  • Goals
    • Avoid irritant
    • Stop inflammation
    • Restore natural protective barrier
  • Avoidance of irritants
    • Must discontinue source of irritation
    • If oral medication, must consider alternative or discontinue entirely (weigh risk vs benefits)
  • Topical NSAIDS
  • Topical Steroids
  • Calcineurin Inhibitors
    • In an RCT, tacrolimus 0.1% (Protopic) was more effective than betamethasone 17-valerate 0.1%[14]
  • Nail Bed Removal
    • May be indicated in severe or refractory cases to stop inflammation, restore barrier
  • Doxycycline
    • Effective for treatment of paronychia caused by antiepidermal growth factor receptor antibodies[15]
  • 1% solution of povidone/iodine in dimethyl sulfoxide
    • Case reports of treatment BID until symptom resolution in chemotherapy induced presentation[16]
  • Zinc Supplement if deficient
  • Not indicated
    • Antifungals

Paronychia Incision and Drainage

  • In most cases, the abscess should be mechanically drained and can be done at bedside
  • After opening, spontaneous drainage should occur, can massage out purulent material
  • Consider Digital Block for anesthesia
  • Antibiotics are generally not needed after successful drainage[17]
  • Post-drainage soaking with or without Burow solution or 1% acetic acid recommended for 2-3 days

Prevention

  • Moisturizing lotion
    • Apply after hand washing.
  • Contact irritants and moisture, e.g. detergent or soap
    • Avoid chronic prolonged exposure
    • Use rubber gloves, preferably with inner cotton glove or cotton liners
  • Avoid nail trauma
    • Biting
    • Picking
    • Manipulation
    • Finger sucking
  • Cuticles
    • Avoid trimming cuticles or using cuticle removers
  • Diabetes Mellitus
    • Improve glycemic control
  • Keep affected areas clean and dry
  • Keep nails short

Operative

  • Indications for chronic
    • More than 6 months duration
    • Lack of response to/failure of medical treatment
  • Technique
    • No incision
    • DAREJD
    • Single incision
    • Double incision
    • Swiss role

Rehab and Return to Play

Rehabilitation

  • No clear guidelines

Return to Play/ Work

  • No clear guidelines

Complications and Prognosis

Prognosis

  • Most patients have an excellent prognosis, depending on the underlying etiology

Complications: acute

  • Subungual abscess
  • Felon
  • Recurrence
  • Progression to chronic paronychia
  • Rarely osteomyelitis (limited to case reports)
  • Nail plate deformity/dystrophy
  • Periungual fibrokeratoma

See Also

Internal

External

References

  1. ↑ Jemec, B., and J. E. Anderson. "Surgical treatment of paronychia granulomatosa hallucis." Acta Dermato-Venereologica 55.4 (1975): 319-320.
  2. ↑ Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001;63(6):1113–1116.
  3. ↑ Patel L. Management of Simple Nail Bed Lacerations and Subungual Hematomas in the Emergency Department. Pediatric Emergency Care. 2014; 30 (10): 742-745. doi: 10.1097/PEC.0000000000000241.
  4. ↑ 4.0 4.1 4.2 Relhan, Vineet, and Anuva Bansal. "Acute and chronic paronychia revisited: A narrative review." Journal of Cutaneous and Aesthetic Surgery 15.1 (2022): 1-16.
  5. ↑ Capriotti K, Capriotti JA, Lessin S, et al. The risk of nail changes with taxane chemotherapy: a systematic review of the literature and meta-analysis. Br J Dermatol. 2015;173(3):842–845.
  6. ↑ Patel, Dakshesh B., et al. "Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options." Radiographics 34.7 (2014): 1968-1986.
  7. ↑ Fowler JR, Ilyas AM. Epidemiology of adult acute hand infections at an urban medical center. J Hand Surg Am. 2013;38(6):1189–1193.
  8. ↑ Leggit, Jeffrey C. "Acute and chronic paronychia." American family physician 96.1 (2017): 44-51.
  9. ↑ Shafritz, Adam B., and Jeff M. Coppage. "Acute and chronic paronychia of the hand." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 22.3 (2014): 165-174.
  10. ↑ Jinnouchi O, Kuwahara T, Ishida S, et al. Anti-microbial and therapeutic effects of modified Burow's solution on refractory otorrhea. Auris Nasus Larynx. 2012;39(4):374–377.
  11. ↑ Nagoba BS, Selkar SP, Wadher BJ, Gandhi RC. Acetic acid treatment of pseudomonal wound infections—a review. J Infect Public Health. 2013;6(6):410–415.
  12. ↑ Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008;58(1):1–21.
  13. ↑ Wollina U. Acute paronychia: comparative treatment with topical antibiotic alone or in combination with corticosteroid. J Eur Acad Dermatol Venereol. 2001;15(1):82–84.
  14. ↑ Rigopoulos D, Gregoriou S, Belyayeva E, Larios G, Kontochristopoulos G, Katsambas A. Efficacy and safety of tacrolimus ointment 0.1% vs. betamethasone 17-valerate 0.1% in the treatment of chronic paronychia: an unblinded randomized study. Br J Dermatol. 2009;160(4):858–860.
  15. ↑ Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008;77(3):339–346.
  16. ↑ Capriotti K, Capriotti JA. Chemotherapy-associated paronychia treated with a dilute povidone-iodine/dimethylsulfoxide preparation. Clin Cosmet Investig Dermatol. 2015;8:489–491.
  17. ↑ Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and soft tissue infections. Am Fam Physician. 2015;92(6):474–483.
Created by:
John Kiel on 19 February 2022 08:37:06
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Last edited:
25 February 2025 23:50:15
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