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 tenderness
- A 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 matrix
- Oral 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)