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Paronychia, Emergency Medicine

Basics

Description

  • Disruption of the seal between the nail plate and the nail fold may allow entry of bacteria into the eponychial space.
  • Inflammation of the nail folds surrounding the nail plate

Etiology

  • Acute paronychia: Predominantly Staphylococcus aureus but also streptococci, Pseudomonas, and anaerobes
  • Chronic paronychia: Multifactorial due to allergens and irritants in addition to fungal etiologies, predominantly Candida albicans, which commonly coexist with Staphylococcus species

Diagnosis

Signs and Symptoms

  • Pain, warmth, and swelling to the proximal and lateral nail folds, often 2 " “5 days after trauma
  • Symptoms must be present for 6 wk to meet criteria for a chronic paronychia.

History

  • Acute paronychia: Nail biting, finger sucking, aggressive manicuring or manipulation, and trauma predispose to development.
  • Chronic paronychia: Occupations with persistent moist hands; dish washers, bartenders; also increased in patients with peripheral vascular disease or diabetes

Frequently anaerobic mouth flora in children from nail biting ‚

Physical Exam

  • Begins as swelling, pain, and erythema in the dorsolateral corner of the nail fold bulging out over the nail plate
  • Progresses to subcuticular/subungual abscess
  • Green nail coloration suggests Pseudomonas
  • Nail plate hypertrophy suggests fungal source

Essential Workup

  • History and physical exam with special attention to evaluating for concomitant infections such as felon or cellulitis
  • Assess tetanus status.

Diagnosis Tests & Interpretation

Lab

  • No specific tests are useful.
  • Cultures are not routinely indicated.
  • Tzanck smear or viral culture if herpetic whitlow suspected.

Imaging

Soft tissue radiographs if foreign body is suspected; routine films if osteomyelitis suspected ‚

Diagnostic Procedures/Surgery

Digital pressure test (opposing the thumb and the affected finger) may help identify the margins of an early subungual abscess ‚

Differential Diagnosis

  • Felon
  • Herpetic whitlow
  • Trauma or foreign body
  • Primary squamous cell carcinoma
  • Metastatic carcinoma
  • Osteomyelitis
  • Psoriasis
  • Reiter syndrome
  • Pyoderma gangrenosum
  • Onychomycosis

Treatment

Ed Treatment/Procedures

Acute Paronychia

  • Early paronychia without purulence may be managed with warm-water soaks 4 times a day with or without oral antibiotics; may also consider topical antibiotics and corticosteroids.
  • Early superficial subcuticular abscess:Elevation of the eponychial fold by sliding the flat edge of a no. 11 blade (18G needle or small clamps may be used) gently between the proximal nail fold and the nail plate near the point of maximal tendernessA digital nerve block or local anesthesia may be necessary.
  • Partial nail involvement:If the lesion extends beneath the nail, remove a longitudinal section of the nail.Petroleum jelly or iodoform gauze packing for 24 hr
  • Runaround abscess:If the lesion extends beneath the base of the nail to the other side, remove 1/4 " “1/3 of the proximal nail with 2 small incisions at the dorsolateral edges of the nail fold and pack eponychial fold with petroleum jelly or iodoform gauze to prevent adherence.
  • Extensive subungual abscess:
  • Early paronychia without purulence present may be managed with warm soaks alone; beyond that, antibiotics are recommended if there is any apparent cellulitis, abscess, or systemic sign of infection.
  • Trimethoprim " “sulfamethoxazole, dicloxacillin, and amoxicillin " “clavulanate are appropriate first-line agents, with treatment regimens ranging from 5 " “10 days, depending on severity.
  • Clindamycin or amoxicillin " “clavulanate if associated with nail biting or oral contact

Chronic Paronychia

  • Avoidance of predisposing exposures and irritants/chemicals
  • Topical steroids should be considered first-line therapy, with or without broad-spectrum topical antifungal agent
  • Consideration for antistaphylococcal regimen
  • For recalcitrant cases:Eponychial marsupialization involving removal of a crescentic piece of skin just proximal to the nail fold, including all thickened tissue down to but not including germinal matrixOral antifungal therapy

Medication

First Line

  • Amoxicillin " “clavulanate: 875 mg PO BID for 7 days (peds: 25 mg/kg/d PO q12h)
  • Trimethoprim " “sulfamethoxazole (Bactrim DS) BID for 7 days
  • Dicloxacillin: 500 mg PO QID for 7 days (peds: 12.5 " “50 mg/kg/d PO q6h)

Second Line

  • Clindamycin: 300 mg PO QID for 7 days (peds: 20 " “40 mg/kg/d div. q6h PO, IV, IM)
  • Topical antibiotics: Polymyxin B/Bacitracin, there is a high incidence of hypersensitivity to neomycin, mucipurin topical (Bactroban), or gentamicin TID for 5 " “10 days (0.1%ointment)
  • Topical antifungal/steroid combination: nystatin " “triamcinolone BID " “TID until resolution, no longer than 1 mo
  • For all topical antibiotics apply a small amount to affected areas TID " “QID

Follow-Up

Disposition

Admission Criteria

Admission is not needed for paronychia alone. ‚

Discharge Criteria

  • Patients with uncomplicated paronychias may be discharged with appropriate follow-up instructions.
  • Patients with packings should be re-evaluated in 24 hr.

Issues for Referral

Chronic paronychias refractory to treatment ‚

Pearls and Pitfalls

  • Acute paronychias respond well to decompression with or without antibiotics.
  • Chronic paronychias are largely a result of chronic exposure to allergens/irritants.
  • Reiter syndrome and psoriasis can mimic paronychia.
  • Recurrent paronychia should raise suspicion for herpetic whitlow.
  • Assess for felons.

Additional Reading

  • Dahdah ‚ MJ, Scher ‚ RK. Nail diseases related to nail cosmetics. Dermatol Clin. 2006;24(2):233 " “239,vii.
  • Jebson ‚ PJ. Infections of the fingertip. Paronychias and felons. Hand Clin. 1998;14:547 " “555, viii.
  • Moran ‚ GJ, Talan ‚ DA. Hand infections. Emerg Med Clin North Am. 1993;11(3):601 " “619.
  • Rigopoulos ‚ D, Larios ‚ G, Gregoriou ‚ S, et al. Acute and chronic paronychia. Am Fam Physician. 2008;77(3):339 " “346.
  • Rockwell ‚ PG. Acute and chronic paronychia. Am Fam Physician. 2001;63(6):1113 " “1116.

Codes

ICD9

  • 112.3 Candidiasis of skin and nails
  • 681.02 Onychia and paronychia of finger
  • 681.9 Cellulitis and abscess of unspecified digit
  • 681.11 Onychia and paronychia of toe

ICD10

  • B37.2 Candidiasis of skin and nail
  • L03.019 Cellulitis of unspecified finger
  • L03.039 Cellulitis of unspecified toe

SNOMED

  • 71906005 Paronychia (disorder)
  • 444646006 Paronychia of finger
  • 388983002 Paronychia of toe
  • 187017007 Candidal paronychia (disorder)
  • 200744008 chronic paronychia (disorder)
  • 247517004 Bacterial paronychia (disorder)