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Paronychia

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|Key=Paronychia, toenail, fingernail, infection, abscess |Description=Paronychia is an inflammatory process of either the toe nail or fingernail. It is commonly associated with infection but can also be due to other processes when seen in it's more chronic form. }}

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

Epidemiology

  • One of the most common hand infections (need citation)
  • Three times more common in women[1]

Pathophysiology

Illustration of the fingernail anatomy[2]
  • 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

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[3]
    • Retinoids
    • Protease inhibitors
    • Antiepidermal growth factor receptor antibodies
    • Chemotherapeutic agents

Associated Conditions


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
      • Abscess is frequently present
    • Chronic
      • Symptoms for at least 6 weeks, positive exposure history, nail dystrophy
      • Mild edema and erythema of the proximal and lateral nail folds with loss of the cuticle
  • 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
  • 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: fluid collection

Laboratory

  • Routine culture is not necessary
    • In a study of patients admitted for paronychia, only 4% of cultures were positive[5]
  • Most common bacteria
    • Staphylococcus aureus, followed by streptococci and Pseudomonas

Classification

  • Acute vs Chronic

Management

Treatment options and common pathogens for acute Paronychia[6]

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[7]
    • 1% Acetic Acid effective for treating multidrug-resistant pseudomonal wound infections[8]
  • 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[9]
  • 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[10]
  • 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%[11]
  • 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[12]
  • 1% solution of povidone/iodine in dimethyl sulfoxide
    • Case reports of treatment BID until symptom resolution in chemotherapy induced presentation[13]
  • Zinc Supplement if deficient
  • Not indicated
    • Antifungals

Operative

  • If abscess is present, 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[14]
    • 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

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

  • Recurrence
  • Progression to chronic paronychia
  • Felon, rarely osteomyelitis (limited to case reports)

See Also


References

  1. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001;63(6):1113–1116.
  2. 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.
  3. 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.
  4. Patel, Dakshesh B., et al. "Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options." Radiographics 34.7 (2014): 1968-1986.
  5. Fowler JR, Ilyas AM. Epidemiology of adult acute hand infections at an urban medical center. J Hand Surg Am. 2013;38(6):1189–1193.
  6. Leggit, Jeffrey C. "Acute and chronic paronychia." American family physician 96.1 (2017): 44-51.
  7. 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.
  8. 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.
  9. Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008;58(1):1–21.
  10. 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.
  11. 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.
  12. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008;77(3):339–346.
  13. Capriotti K, Capriotti JA. Chemotherapy-associated paronychia treated with a dilute povidone-iodine/dimethylsulfoxide preparation. Clin Cosmet Investig Dermatol. 2015;8:489–491.
  14. 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:
14 March 2022 11:13:21
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