We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Paronychia
From WikiSM
Contents
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
- Acute
- Chronic
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
- Fractures
- Dislocations
- Tendinopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Nail Bed Injuries
- Pediatric Considerations
- Other
Differential Diagnosis Foot Pain
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Plantar Fasciopathy (Plantar Fasciitis)
- Turf Toe
- Plantar Plate Tear
- Spring Ligament Injury
- Neuropathies
- Mortons Neuroma
- Tarsal Tunnel Syndrome
- Joggers Foot (Medial Plantar Nerve)
- Baxters Neuropathy (Lateral Plantar Nerve)
- Arthropathies
- Hallux Rigidus (1st MTPJ OA)
- Gout
- Toenail
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Freibergs Disease (Avascular Necrosis of the Metatarsal Head)
Clinical Features
- 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
- Acute
- 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
- Digital Pressure Test: pressure applied can help identify presence of abscess
Evaluation
- Primarily clinical a clinical diagnosis where laboratory and imaging is not required
Radiographs
- Standard Radiographs Hand
- Can be used to help exclude / include other pathology
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
- 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
External
- Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
References
- ↑ Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001;63(6):1113–1116.
- ↑ 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.
- ↑ 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.
- ↑ Patel, Dakshesh B., et al. "Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options." Radiographics 34.7 (2014): 1968-1986.
- ↑ Fowler JR, Ilyas AM. Epidemiology of adult acute hand infections at an urban medical center. J Hand Surg Am. 2013;38(6):1189–1193.
- ↑ Leggit, Jeffrey C. "Acute and chronic paronychia." American family physician 96.1 (2017): 44-51.
- ↑ 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.
- ↑ 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.
- ↑ Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008;58(1):1–21.
- ↑ 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.
- ↑ 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.
- ↑ Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008;77(3):339–346.
- ↑ Capriotti K, Capriotti JA. Chemotherapy-associated paronychia treated with a dilute povidone-iodine/dimethylsulfoxide preparation. Clin Cosmet Investig Dermatol. 2015;8:489–491.
- ↑ 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
Authors:
Last edited:
16 October 2022 00:24:30
Categories: