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Paronychia
Nancy V. Nguyen, DO
image BASICS
DESCRIPTION
  • Superficial inflammation of the lateral and posterior folds of skin surrounding the fingernail or toenail
    • Acute: characterized by pain, erythema, and swelling; usually a bacterial infection, appears after trauma. It can progress to abscess formation.
    • Chronic: characterized by swelling, tenderness, cuticle elevation, and nail dystrophy and separation lasting at least 6 weeks, or recurrent episodes of acute eponychial inflammation and drainage.
    • May be considered work-related among bartenders, waitresses, nurses, and others who often wash their hands
  • System(s) affected: skin and nail bed
  • Synonym(s): eponychia; perionychia
Pediatric Considerations
Less common in pediatric age groups. Thumb/fingersucking is a risk factor (anaerobes and Escherichia coli may be present).
EPIDEMIOLOGY
Incidence
  • Common in the United States
  • Predominant age: all ages
  • Predominant sex: female > male
ETIOLOGY AND PATHOPHYSIOLOGY
  • Acute: Staphylococcus aureus (1) most common and Streptococcus pyogenes (1); less frequently, Pseudomonas pyocyanea and Proteus vulgaris. In digits exposed to oral flora especially in pediatric age group, consider Eikenella corrodens, Fusobacterium, and Peptostreptococcus.
  • Chronic: eczematous reaction with secondary Candida albicans (˜95%) (2)
  • A paronychial infection commonly starts in the lateral nail fold.
  • Recurrent inflammation, persistent edema, and fibrosis of nail folds cause nail folds to round up and retract, exposing nail grooves to irritants, allergens, and pathogens.
  • Inflammation compromises ability of proximal nail fold to regenerate cuticle leading to decreased vascular supply. This can cause decrease efficacy of topical medications.
  • Early in the course, cellulitis alone may be present. An abscess can form if the infection does not resolve quickly.
RISK FACTORS
  • Acute: direct or indirect trauma to cuticle or nail fold, manicure/sculptured nails, nail biting, and thumb sucking and predisposing conditions such as diabetes mellitus (DM)
  • Chronic: frequent immersion of hands in water with excoriation of the lateral nail fold (e.g., chefs, bartenders, housekeepers, swimmers, dishwashers, nurses), DM, immunosuppression (reported association with antiretroviral therapy for HIV and with use of epidermal growth factor inhibitors) (3)
GENERAL PREVENTION
  • Acute: Avoid trauma such as nail biting; prevent thumb sucking.
  • Chronic: Avoid allergens; keep fingers/hands dry; wear rubber gloves with a cotton liner. Prevent excoriation of the skin.
  • Keep nails short. Avoid manicures. Apply moisturizer after washing hands.
  • Good glycemic control in diabetic patients
COMMONLY ASSOCIATED CONDITIONS
  • DM
  • Eczema or atopic dermatitis
  • Certain medications: antiretroviral therapy (3) (especially protease inhibitors, indinavir, and lamivudine, in which toes more commonly involved) (3)
  • Immunosuppression (4)
image DIAGNOSIS
PHYSICAL EXAM
  • Acute: red, warm, tender, tense posterior or lateral nail fold ± abscess
  • Chronic: swollen, tender, boggy nail fold ± abscess
  • Occasional elevation of nail bed
  • Separation of nail fold from nail plate
  • Red, painful swelling of skin around nail plate
  • Fluctuance, purulence at the nail margin, or purulent drainage
  • Secondary changes of nail platelike discoloration
  • Suspect Pseudomonas if with green changes in nail (chloronychia) (5).
  • Positive fluctuation when mild pressure over the area causes blanching and demarcation of the abscess
  • Chronic: retraction of nail fold and absence of adjacent healthy cuticle, thickening of nail plate with prominent transverse ridges known as Beau lines and discoloration
DIFFERENTIAL DIAGNOSIS
  • Felon (abscess of fingertip pulp; urgent diagnosis required)
  • Contact dermatitis
  • Herpetic whitlow (similar in appearance, very painful, often associated with vesicles)
  • Acute osteomyelitis of the distal phalanx
  • Psoriasis especially acute flare
  • Allergic contact dermatitis (latex, acrylic)
  • Reiter disease
  • Pustular psoriasis
  • Proximal/lateral onychomycosis (nail folds not predominantly involved)
  • Malignancy: squamous cell carcinoma of the nail, malignant melanoma, metastatic disease
DIAGNOSTIC TESTS & INTERPRETATION
None required unless condition is severe; resistant to treatment or if recurrence or methicillin-resistant S. aureus (MRSA) is suspected, then
  • Gram stain
  • Culture and sensitivity
  • Potassium hydroxide wet mount plus fungal culture especially in chronic
  • Drugs that may alter lab results: Use of over-the-counter antimicrobials or antifungals.
Diagnostic Procedures/Other
  • Incision and drainage recommended for suppurative cases or cases not responding to conservative management or empiric antibiotics
  • Tzanck testing or viral culture in suspected viral cases
  • Biopsy in cases not responding to conservative management or when malignancy suspected
image TREATMENT
GENERAL MEASURES
  • Acute: warm compresses, elevation, splint protection if pain severe
  • Chronic: Keep fingers dry; apply moisturizing lotion after hand washing; avoid exposure to irritants; improved diabetic control
MEDICATION
First Line
  • Tetanus booster when indicated
  • Acute (mild cases, no abscess formation)
    • Topical antibiotic cream alone or in combination with a topical steroid (6)[B]
    • P.765

    • Antibiotic cream applied TID-QID after warm| soak (e.g., mupirocin or gentamicin/neomycin/polymyxin B) for 5 to 10 days
    • If eczematous: low-potent topical steroid applied BID (e.g., betamethasone 0.05% cream) for 7 to 14 days (7)[B]
  • Acute (no exposure to oral flora)
    • Dicloxacillin 250 mg TID for 7 days
    • Cephalexin 500 mg TID-QID for 7 days
  • Acute (suspected MRSA)
    • Trimethoprim/sulfamethoxazole 160 mg/800 mg BID for 7 days
    • Doxycycline 100 mg BID for 7 days
  • Acute (exposure to oral flora)
    • Amoxicillin clavulanate: 875 mg/125 mg BID or 500 mg/125 mg TID for 7 days; pediatric, 45 mg/kg q12h (for <40 kg)
    • Clindamycin 300 to 450 mg TID-QID for 7 days; pediatric, 10 mg/kg q8h; plus either doxycycline or trimethoprim/sulfamethoxazole
  • Chronic
    • Topical steroids: betamethasone 0.05%; applied BID for 7 to 14 days (8)[B]
    • Topical antifungal: clotrimazole or nystatin; applied topically TID for up to 30 days
    • Other topical: Tacrolimus 0.1% ointment BID for up to 21 days has been shown to be effective but is more expensive.
Second Line
  • Systemic antifungals (rarely needed, use if topical fails)
    • Itraconazole 200 mg for 90 days (may have longer action because it is incorporated into nail plate); pulse therapy may be useful (i.e., 200 mg BID for 7 days, repeated monthly for 2 months) (1)[C],(8)
    • Terbinafine 250 mg/day for 6 weeks (fingernails) or 12 weeks (toenails)
    • Fluconazole 100 mg daily for 7 to 14 days
    • Ciclopirox 0.77% topical suspension BID for 2 to 4 weeks along with strict irritant avoidance (7)[B]
  • Antipseudomonal drugs (e.g., ceftazidime, aminoglycosides) when pseudomonas is suspected
ISSUES FOR REFERRAL
Chronic; in treatment failure, consider biopsy and/or, in cases of chronic paronychia, referral for possible partial excision of the nail fold or eponychial marsupialization with or without complete nail removal.
SURGERY/OTHER PROCEDURES
  • Incision and drainage of abscess, if present
  • A subungual abscess or ingrown nail requires partial or complete removal of nail with phenolization of germinal matrix.
  • Recalcitrant cases may also need nail removal.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Chronic: Avoid frequent immersion, triggers, allergens, or nail biting and finger sucking.
DIET
If patient is diabetic, consider appropriate dietary and medication changes for better control.
PATIENT EDUCATION
  • Avoid trimming cuticles; avoid nail trauma; and stress importance of good diabetic control and diabetic education.
  • Avoid contact irritants; use rubber gloves with cotton liners to avoid exposure to excess moisture.
  • Use moisturizing lotion after washing hands; do not bite nails/suck on fingers.
PROGNOSIS
  • With adequate treatment and prevention, healing can be expected in 1 to 2 weeks.
  • Chronic paronychia may respond slowly to treatment, taking weeks to months.
  • If no response in chronic lesions, rarely benign or malignant neoplasm may be present and referral should be considered.
REFERENCES
1. Rigopoulos D, Larios G, Gregoriou S, et al. Acute and chronic paronychia. Am Fam Physician. 2008;77(3):339-346.
2. Barlow AJ, Chattaway FW, Holgate MC, et al. Chronic paronychia. Br J Dermatol. 1970;82(5): 448-453.
3. 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.
4. Tosti A, Piraccini BM, D'Antuono A, et al. Paronychia associated with antiretroviral therapy. Br J Dermatol. 1999;140(6):1165-1168.
5. Rigopoulos D, Gregoriou S, Belyayeva E, et al. 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.
6. Tosti A, Piraccini BM, Ghetti E, et al. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002;47(1):73-76.
7. Daniel CR III, Daniel MP, Daniel J, et al. Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen. Cutis. 2004;73(1):81-85.
8. Relhan V, Goel K, Bansal S, et al. Management of chronic paronychia. Indian J Dermatol. 2014;59(1): 15-20.
Additional Reading
&NA;
  • Chiriac A, Brzezinski P, Foia L, et al. Chloronychia: green nail syndrome caused by Pseudomonas aeruginosa in elderly persons. Clin Interv Aging. 2015;10:265-267.
  • Hengge UR, Bardeli V. Images in clinical medicine. Green nails. N Engl J Med. 2009;360(11):1125.
  • Iorizzo M. Tips to treat the 5 most common nail disorders: brittle nails, onycholysis, paronychia, psoriasis, onychomycosis. Dermatol Clin. 2015; 33(2):175-183.
  • Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001;63(6):1113-1116.
  • Shroff PS, Parikh DA, Fernandez RJ, et al. Clinical and mycological spectrum of cutaneous candidiasis in Bombay. J Postgrad Med. 1990;36(2):83-86.
See Also
&NA;
Onychomycosis
Codes
&NA;
ICD10
  • L03.019 Cellulitis of unspecified finger
  • L03.039 Cellulitis of unspecified toe
Clinical Pearls
&NA;
  • Consider tetanus booster when indicated.
  • Consider incision and drainage when appropriate. Send culture.
  • For chronic paronychia, topical steroid is first-line treatment. Consider other differentials in nonresponders (e.g., rare causes: Raynaud, metastatic cancer, psoriasis, drug toxicity)
  • For chronic nonhealing lesion, consider dermatology referral.
  • Consider possibility of cancer if chronic inflammatory process is unresponsive to treatment.
  • Consider presence of more than one nail disease at the same time (e.g., paronychia and onychomycosis).