Updated: 1/2/2019

Paronychia

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Snapshot
  • A 25-year-old woman presents to the nail clinic for a painful middle finger. She obtains regular manicures, changing colors every 2 weeks. She recently had one a week ago and started feeling pain near the nail on her left middle finger. Her current medications include isotretinoin for treatment of acne. Physical exam reveals an erythematous proximal nail fold of the middle finger. When applying pressure to the nail plate, some pus drains from the nail. She is prescribed frequent warm soaks with chlorhexidine and oral antibiotics.
Introduction
  • Clinical definition
    • inflammation of skin around the nail
      • acute paronychia
        • duration less than 6 weeks
        • caused by bacterial infection
      • chronic paronychia
        • duration 6 weeks or more
        • caused by chronic exposure to irritant or allergens
  • Epidemiology
    • incidence
      • very common
    • risk factors
      • for acute paronychia
        • nail biting
        • finger sucking
        • manicures
        • pedicures
        • ingrown nails
      • for chronic paronychia
        • occupations such as a dishwasher, barber, and healthcare professionals
      • for both
        • diabetes
        • immunosuppression
        • drugs
          • retinoids
          • antiretroviral therapy
  • Etiology
    • acute paronychia
      • Staphylococcus aureus
      • γ-hemolytic streptococci
      • Eikenella corrodens
      • group A β-hemolytic streptococci
      • Candida
    • chronic paronychia
      • repeated exposure to environmental irritants
      • a type of hand dermatitis, not a type of infection
  • Pathogenesis
    • acute paronychia
      • active infection following minor trauma to nail bed or cuticles
    • chronic paronychia
      • nail plate separation from cuticle with inflammation
      • can have subsequent yeast or bacterial colonization
  • Prognosis
    • acute paronychia typically responsive to treatment
    • chronic paronychia is responsive to treatment, though responds very slowly
      • resolves in weeks or even months
Presentation
  • Symptoms
    • pain
  • Physical exam
    • swelling and erythema of the proximal or lateral nail folds
      • tender to palpation
    • retraction of proximal nail fold
    • pus under nail fold
    • abscess
      • digital pressure test
        • blanch the nail to look for demarcation of abscess
    • acute paronychia
      • typically a single digit
    • chronic paronychia
      • typically several fingernails, most commonly the thumb, second, or third finger
      • thickening or discoloration of nail
Studies
  • Diagnosis is usually based on clinical history and physical exam
Differential
  • Trauma
  • Herpetic whitlow
    • positive Tzanck test
  • Psoriasis
  • Felon
    • abscess of the pulp space
    • treatment 
      • incision and drainage
      • antibiotics
Treatment
  • Conservative
    • warm soaks
      • indication
        • symptomatic relief
      • modalities
        • aluminum acetate
        • vinegar
        • dilute povidone-iodine
        • chlorhexidine
  • Medical
    • topical antibiotics
      • indication
        • acute paronychia
        • minimal erythema and no abscess
        • added to warm soaks
      • drugs
        • gentamicin
        • mupirocin
    • oral antibiotics
      • indication
        • persistent acute paronychia
      • drugs
        • trimethoprim-sulfamethoxazole
        • clindamycin
    • topical steroids
      • indication
        • chronic paronychia
      • drugs
        • betamethasone
  • Operative
    • incision and drainage
      • indication
        • if an abscess is present
Complications
  • Permanent nail plate dystrophy

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