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Paronychia

Paronychial Inflammation of the Nail

Paronychia is a superficial infection of epithelium lateral to the nail plate, most commonly caused by staphylococci or fungi.


Presentation

Paronychia generally begins with swelling and pain around the sides or base of the nail [6]. Acute paronychia can lead to pus-filled pockets that can be found at the side or base of the fingernails or toenail. Chronic paronychia generally causes a break down in cuticle and may force a separation of the nail from the skin. The nail may become thick, hard and deformed.

If the paronychia is caused by bacteria, it can deteriorate very quickly. If it is caused by fungus, the progression is a lot slower.

Axillary Lymphadenopathy
  • The giveaway is usually axillary lymphadenopathy, biopsy of which grows Mycobacterium tuberculosis.[stemlynsblog.org]
Fever
  • This is a case report of a child with chronic blastomycosis presenting with chronic paronychia, fever, cough, malaise, and back pain. The child underwent surgical drainage of a paravertebral abscess and administration of intravenous amphotericin B.[ncbi.nlm.nih.gov]
  • The person has a fever and red streaks around the nail, nail discoloration, or joint or muscle pain. The person has diabetes. 4. Follow Up If you seek medical help: The doctor may sample pus or fluid and prescribe an oral antibiotic.[webmd.com]
  • […] a fever) or are feeling worse overall, you need to give me a call.[davidlnelson.md]
  • If you are diabetic, have several affected fingers or toes, or have severe symptoms (pus, fever, severe pain), you must be evaluated by a doctor. In most cases, your doctor can make the diagnosis by examining the affected area.[2minutemedicine.com]
  • The individual should contact her health care provider if the swelling or pain worsen, pus begins to drain, or she has a fever.[livestrong.com]
Candidiasis
  • In 8 patients with proven and severe candidiasis of the nails, oral fluconazole 100 mg was added for 20 days. All patients with bacterial perionyxis took clarithromycin 500 mg twice daily for six days. Patients were then followed for 8 weeks.[ncbi.nlm.nih.gov]
  • When candidiasis is suspected, the area should be kept dry and treated with local applications of nystatin or other topical antifungals. A long course of systemic medication may be required. Followup with a podiatrist is important.[ncemi.org]
  • When candidiasis is suspected, the area should be kept dry and treated with local applications of nystatin or a topical antifungal medication combined with a topical steroid (e.g., betamethasone 0.05% clotrimazole 1% [Lotrisone] cream).[aneskey.com]
  • Other conditions associated with abnormalities of the nail fold that predispose individuals to chronic paronychia include psoriasis, mucocutaneous candidiasis, and drug toxicity from medications such as retinoids, epidermal growth factor receptor inhibitors[emedicine.medscape.com]
Nail Abnormality
  • Evaluation of nail abnormalities. Am Fam Physician. 2012;85(8):779–787. 29. Tosti A, Piraccini BM, Ghetti E, Colombo MD.[aafp.org]
Foot Pain
  • My foot pain may not rule the rest of my life after all! I believe I'll make a sign that reads, "THE END IS NEAR!"[foot-pain-explained.com]
Joint Deformity
  • Nail involvement led to an early presentation and timely diagnosis and treatment before progression to permanent bone or joint deformity. 2012 Wiley Periodicals, Inc.[ncbi.nlm.nih.gov]
Nail Deformity
  • deformity may result; - curretting may result in full thickness loss of matrix in that area which result in very severe nail bed deformity if left untreated; - salvage treatment consists of removing a split thickness graft fromm adjacent normal matrix[wheelessonline.com]
  • Paronychia symptoms include: swelling, tenderness, and redness around the nail puss-filled abscesses hardening of the nail deformation or damage to the nail the nail separating from the nailbed Causes Biting the nails or the skin around the nails can[medicalnewstoday.com]
Chronic Dermatitis
  • Continued irritation of the area leads to the development of chronic dermatitis. Due to the nearness of the underlying matrix, secondary plate abnormalities may develop. To prevent acute paronychia, proper care of the nails is important.[symptoma.com]
  • Chronic paronychia: Repeated inflammatory processes due to different detergents causing chronic dermatitis, which results in swelling, redness and pain (all of which are less intense compared to the acute phase). Pus formation is uncommon.[dermatologyadvisor.com]

Workup

Paronychia can be diagnosed with the aid of a simple physical exam. In many cases, special tests are not necessary but it may be important to send a sample of fluid or pus to the laboratory in a bid to identify bacteria or fungus that is responsible for the infection [7].

To identify the organism causing the condition, routine Gram staining and culture is often used [8]. Tzanck smears can be performed if herpetic whitlow is suspected in any case. On suspicion of osteomyelitis, a plain film radiograph can be obtained. This will help prevent a recurrence of the infection.
A radiograph can also be obtained if the patient has a recent history of finger trauma or if a foreign body is suspected.

Pseudomonas
  • ., Staphylococcus aureus, alpha-hemolytic streptococci, group A beta-hemolytic streptococci, Klebsiella pneumoniae, Neisseria spp. and Pseudomonas aeruginosa.[ncbi.nlm.nih.gov]
  • Ciprofloxacin ) Pseudomonas coverage (green discharge) Ciprofloxacin XIV.[fpnotebook.com]
  • But there are other bacteria that less frequently cause infections and are commonly of the Streptococcus species as well as Pseudomonas species.[byebyedoctor.com]
Gram-Positive Bacteria
  • RESULTS: We identified 20 different species, among these 72% Gram-positive bacteria, 23% Gram-negative bacteria and 5%Candida species.[ncbi.nlm.nih.gov]

Treatment

Treating paronychia is entirely dependent on the seriousness of the condition. In situations where the symptoms are detected early, paronychia that doesn’t have abscess formation and can be fully treated nonsurgically. However if there is abscess, it can be managed by draining the pus via a small incision [9].

To treat acute paronychia, the affected finger can be treated by regular warm soaks of 3 to 4 times per day until symptoms are relieved. The warm soaks can be supported with antibiotics like clindamycin, clavulanic acid and amoxicillin.

Treatment of chronic paronychia focuses on protecting the finger from moist areas. With the affected area kept dry, the chances of recovery is higher. This can be supported medically with the application of topical antifungal creams. Miconazole is among the first agents that can be used but oral fluconazole and ketoconazole can also be helpful.

If after the best possible medical management the paronychia is not resolved, surgical management may be required. For acute paronychia, the no-incision procedure is what is often followed. The pus is often drained by lifting the eponychial fold with the aid of a small blunt instrument [10].

For chronic paronychia, the eponychial marsupialisation is the surgical procedure of choice. The technique simply involves anesthetisation of the affected finger with 1% lidocaine. A crescent-shaped incision is then made around the distal edge of the eponychial fold. All the affected tissues within the boundaries of the crescent-shaped incision are excised with the exception of the germinal matrix. The excised part is packed with plain gauze and changed every 2 to 3 days.

Prognosis

If treated properly and promptly, prognosis is good for paronychia [5]. However, it can also lead to more serious infections such as osteomyelitis and septic tenosynovitis. It may also give rise to a whitlow as a result of its spreading to the pulp space of the finger.

Infection such as this is seen commonly with patients of immunosuppression and in people whose conditions have been mistreated or neglected. Other complications that may arise include nail loss, discoloration, thickening or secondary ridging

Etiology

The ground for a case of paronychia is set by injury to the area [2]. The injury may arise as a result of picking a hangnail, trimming or pushing back of the cuticle and biting off. The condition is caused by bacteria and fungi. There are various types of fungi that can cause the condition but candida yeast is the most common.
A combination of fungal and bacterial fungal infection is possible.

Fungal paronychia can occur in people who have a fungal nail infection and diabetes. It may also be seen in people guilty of leaving their hands in water for an extended period of time.

Epidemiology

Paronychia is a common infection around the world. In the United States however, it is responsible for at least 35% of reported hand infection cases [3]. There is also gender based disparity as it is seen three times more in women.

Sex distribution
Age distribution

Pathophysiology

In acute paronychia, the breaking down of barrier opens up a pathway allowing bacteria and other microorganisms to get under the part of the finger or toes that is otherwise impenetrable [4]. This leads to an acute bacterial infection of the soft tissues around the finger nail. In some cases, it can get under the nail plate.

In chronic paronychia, negative changes to the cuticle and proximal nail fold makes it easy for water and other irritants to come in contact with the undersides of the proximal nail fold. The resultant environment provides optimal environment for the growth of yeast. Continued irritation of the area leads to the development of chronic dermatitis.

Due to the nearness of the underlying matrix, secondary plate abnormalities may develop.

Prevention

To prevent acute paronychia, proper care of the nails is important. This means avoiding bites on the nails, injuries to nails and fingertips, keeping the nails trimmed and smooth, avoiding the cutting of nails too short, avoiding the trimming o the cuticle, etc. It is also important to use clean scissors and clippers.

Chronic paronychia can be avoided by keeping the hands dry and free from chemicals. Gloves must be worn when working with water or harsh chemicals and socks should be changed at least every day. Avoid wearing the same shoes two days in row to give them the chance to dry out properly.

Summary

Paronychia is the infection of the skin surrounding the toenails and fingernails [1]. It generally affects the skin at the base or around the sides. There are two main types of paronychia, acute paronychia and chronic paronychia. Acute paronychia generally occurs in just one nail while chronic paronychia occurs in more than one nail at once. Chronic paronychia is harder to remedy as it takes longer to clear and may recur in future.

Patient Information

Paronychia is a condition where the corner or side of the nails grow into a soft flesh. This leads to pain, redness, swelling and in many cases, an infection. It can affect any finger.

The condition can be treated with a combination hygiene and use of antibiotics in many cases. The outlook is very positive unless complications arise.

References

Article

  1. Hand. In: Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 5th ed. St. Louis, Mo: Mosby; 2002:529-30.
  2. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. Feb 1 2008;77(3):339-46.
  3. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. Mar 15 2001;63(6):1113-6.
  4. Roberts JR, Hedges JR. Incision and drainage. In: 4th ed. Clinical Procedures in Emergency Medicine. Philadelphia, Pa: WB Saunders Company; 2004:738-41.
  5. Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. Jul 2002;47(1):73-6. 
  6. Rich P. Nail disorders. Diagnosis and treatment of infectious, inflammatory, and neoplastic nail conditions. Med Clin North Am. 1998;82:1171–83,vii.
  7. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 3d ed. St. Louis: Mosby, 1996.
  8. Hochman LG. Paronychia: more than just an abscess. Int J Dermatol. 1995;34:385–6.
  9. Roberge RJ, Weinstein D, Thimons MM. Perionychial infections associated with sculptured nails. Am J Emerg Med. 1999;17:581–2.
  10. Brook I. Aerobic and anaerobic microbiology of paronychia. Ann Emerg Med. 1990;19:994–6.

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Last updated: 2019-07-11 22:34