Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
This article have been viewed 2138 times
Richard B. Mallett
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Paronychia is characterized by inflammation of the proximal and/or lateral nailfolds, the fingers being more commonly affected than the toes. Acute paronychia is a painful pyogenic infection that usually occurs after injury or minor trauma and is characteristically caused by Staphylococcus aureus, although other aerobic and anaerobic bacteria have also been found.
Chronic paronychia, one of the commonest nail disorders, presents as tender erythema of the nailfolds with thickening of the tissues, loss of the cuticle, and subsequent dystrophy of the nail plate. The causative factors are repetitive microtrauma and exposure to water, irritants, and allergens, causing a contact dermatitis with subsequent colonization by yeasts and bacteria. Other less common causes of chronic paronychia include retronychia, characterized by the disruption of the longitudinal growth of a nail due to acute injury from physical or systemic causes, with resultant embedding of the old nail in the ventral surface of the proximal nailfold as the new nail regenerates. Also, cutaneous leishmaniasis may rarely present as an unusual chronic paronychia in endemic areas. Pemphigus vulgaris may present with either acute or chronic paronychia.
Drug-induced paronychia with pseudopyogenic granuloma is increasingly recognized and may occur with systemic retinoids, antiretroviral drugs such as indinavir, epidermal growth factor (EGF) receptor inhibitors, including gefitinib and cetuximab, and the novel anticancer mTOR inhibitors such as everolimus.
Tumors including Bowen’s disease, keratoacanthomas, squamous cell carcinoma, enchondroma, and amelanotic melanoma may masquerade as chronic paronychia.
Acute paronychia requires urgent effective treatment to prevent damage to the nail matrix. If the infection is superficial and pointing, then incision and drainage without anesthesia is possible. Infection is often due to S. aureus, but β-hemolytic streptococci and anaerobic organisms may also be found. A swab must be taken for bacterial culture and antibiotic sensitivity, and a broad-spectrum antibiotic covering both aerobic and anaerobic organisms given. Warm compresses with an astringent (e.g., aluminum acetate lotion, if available) can help reduce edema and provide a hostile environment for bacteria. For deeper infections, if there has been no marked clinical improvement after 48 hours of antibiotic therapy, surgical treatment should be undertaken. Under local anesthesia, the proximal third of the nail plate is removed and a gauze wick is laid under the proximal nailfold to allow drainage.
Chronic paronychia is usually due to dermatitis and often associated with wet work (e.g., in domestic workers, cooks, bartenders, fishmongers, etc.), and may be exacerbated by contact irritants or allergens. Immediate sensitivity to fresh foods can be a factor. In children, thumb sucking may initiate the condition. Eczema or psoriasis may predispose to chronic paronychia, as may poor peripheral circulation and rarely pemphigus vulgaris. Microtrauma, including over-zealous manicuring of the cuticle, is also important. The middle and index fingers of the right hand and the middle finger of the left hand are most commonly affected, but any finger may be involved. Inflammation with bolstering of the nailfold and loss of the cuticle opens a space between the nailfold and the nail plate, which commonly becomes infected with yeast, especially Candida species, and a wide range of other microorganisms. Acute exacerbations due to bacterial infection may occur.
Successful treatment relies on protection of the affected fingers from water, irritants, allergens, and trauma, together with anti-inflammatory treatment using moderately potent or potent topical corticosteroids. Tacrolimus 0.1% ointment applied twice daily may also be effective. Swabs for yeast and bacteria should be taken, anticandidal preparations can be useful, and antibiotic preparations may also be needed. Treatment should be continued until the inflammation has subsided and the cuticle reformed and reattached to the nail plate (3 months or more). Applying 80% phenol with a toothpick to the groove under the proximal nailfold may encourage reattachment. For frequent acute episodes, intralesional or systemic corticosteroids plus systemic antibiotics for a week may be useful. In cases where conservative management fails, surgery or low-dose superficial radiotherapy may be considered. For cases secondary to retronychia simple avulsion of the nail plate can be curative.
Drug-induced pseudopyogenic granulomatous paronychia responds to daily topical 2% mupirocin with clobetasol propionate ointment. Additionally, for patients on EGF or mTOR inhibitors oral doxycycline 100 mg bid or dose reduction may be useful.
Skin swabs
Open patch tests
Whitehead SM, Eykyn SJ, Phillips I. Br J Surg 1981; 68: 420–2.
Swabs were taken from 116 acute paronychias. Anaerobes or mixed aerobes and anaerobes were isolated in 30%. Of 81 paronychias with aerobic organisms only, S. aureus was isolated in 69%.
Frain-Bell W. Trans St John’s Hosp Dermatol Soc 1957; 38: 29–35.
On culture, Candida albicans was grown in 70%, and bacteria, including S. aureus, in 10%.
An excellent overview.
Tosti A, Guerra L, Morelli R, Bardazzi F, Fanti PA. J Am Acad Dermatol 1992; 27: 706–10.
Nine of 20 food handlers with chronic paronychia had positive reactions to 20-minute open patch tests with suspected fresh foods, including wheat flour, egg, chicory, and tomatoes.
Brook I. J Hand Surg [Br] 1993; 18: 358–9.
Culture from 61 patients with paronychia showed a mixture of both aerobic and anaerobic bacteria in 49%. The combination of amoxicillin with clavulinic acid is suggested as first-line treatment for acute bacterial paronychia, together with appropriate surgical drainage.
Haneke E, Baran R, Brauner GJ. In: Baran R, Dawber RP, eds. Diseases of the Nails and their Management, 2nd edn. Oxford: Blackwell Scientific, 1994; 408.
For acute paronychia, under local anesthesia the proximal third of the nail plate is removed and a wick laid under the proximal nailfold.
Tosti A, Piraccini BM, Ghetti E. J Am Acad Dermatol 2002; 47: 73–6.
An open, randomized, double-blind trial of oral itraconazole, oral terbinafine, and topical methylprednisolone aceponate. Patients were treated for 3 weeks and observed for a further 6 weeks. Of 48 nails treated with methylprednisolone aceponate, 41 (85%) were improved or cured at the end of the study, compared to only 30 of 57 (53%) with itraconazole and 29 of 64 (45%) with terbinafine.
Rigopoulos D, Gregoriou S, Belyayeva E, et al. Br J Dermatol 2009; 160: 858–60.
This open study showed that topical tacrolimus 0.1% and betamethasone 17-valerate 0.1% ointments applied twice daily to the affected perionychium both gave statistically significantly better cure or improved rates compared with placebo. Also, in this study, tacrolimus 0.1% ointment appeared to be more effective than betamethasone 17-valerate 0.1% ointment.
Hay RJ. J Am Acad Dermatol 1999; 40: S35–42.
The central role of Candida in chronic paronychia is debatable, and other factors such as irritant or allergic dermatitis may play a role. Therefore, as well as polyenes or imidazoles, concomitant use of a topical corticosteroid is a logical approach.
Silverman RA. In: Callen JP, Dhal MV, Golitz LE, et al, eds. Advances in Dermatology. Vol 5. Chicago: Mosby Year Book, 1990; 164–5.
Clotrimazole drops several times a day should inhibit fungal growth. Topical clindamycin solution applied to the fingers several times daily kills bacteria, has a bitter taste to discourage finger sucking, and has an alcohol–propylene glycol vehicle that dries out residual moisture. Side effects from oral absorption of these medications have not been reported.
Gahdah MJ, Kibbi AG, Ghosn S. J Am Acad Dermatol 2008; 58: 1051–3.
Two cases of paronychia due to retronychia, a term coined by de Berker et al. in 1999, successfully treated with simple nail avulsion.
Tosti A, Piraccini BM, D’Antuono A, et al. Br J Dermatol 1999; 140: 1165–8.
Six cases of periungual pseudopyogenic granuloma induced by indinavir, lamivudine, and zidovudine responded to daily applications of clobetasol propionate and mupirocin.
Suh K-Y, Kindler HL, Medenica M, et al. Br J Dermatol 2006; 154: 191–2.
During treatment with cetuximab a patient developed painful paronychia, refractory to topical mupirocin and cefalexin but improved after treatment with doxycycline 100 mg twice daily.
Sibaud V, Dalenc F, Mourey L, et al. Acta Derm Venereol 2011; 91: 584–5.
Seven patients treated with mTOR inhibitors presenting with chronic paronychia were treated variously with topical steroids, silver nitrate, topical antibiotics, and oral doxycycline and pristinamycin; three patients required dose reduction.
Vickers HR. Br Med J 1979; 2: 1588.
A nystatin-containing ointment should be worked into the affected nailfold every time the patient is going to get the hands wet, for at least 6 weeks.
Hay RJ, Baran R, Haneke E. In: Baran R, Dawber RP, eds. Diseases of the Nails and their Management, 2nd edn. Oxford: Blackwell Scientific, 1994; 119–20.
For frequent acute exacerbations of chronic paronychia, intralesional or systemic corticosteroids plus either erythromycin 1 g daily or tetracycline 1 g daily for a week is recommended.
Graham CE. Med J Aust 1992; 156: 512.
Acute paronychia successfully treated with leeches while trekking in Tasmania.
Bednar MS, Lane LB. J Hand Surg [Am] 1991; 16: 314–17.
Twenty-eight fingers with chronic paronychia were treated with marsupialization of the dorsal roof of the proximal nailfold plus complete or partial removal of the nail in those patients with associated nail abnormality. Postoperative treatment was with hydrogen peroxide soaks and oral antibiotics for 5 to 14 days. Twenty-seven of 28 fingers were cured.
Baran R, Bureau H. J Dermatol Surg Oncol 1981; 7: 106–7.
Description of the technique of simple excision of the affected nailfold without the need for marsupialization.
Fliegelman MT, Lafayette GO. Postgrad Med 1970; 48: 267–8.
For recalcitrant cases of chronic paronychia, triamcinolone can be injected into the affected nailfold. For the most severe cases, a course of low-dose superficial radiotherapy may be given.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
WhatsApp us
Amoxicillin with clavulinic acid
Surgical drainage
Topical corticosteroid preparations
Topical tacrolimus 0.1% ointment
Topical clotrimazole drops
Topical clindamycin solution
Avulsion of nail plate
Mupirocin and clobetasol propionate
Doxycycline
Dose reduction
Nystatin ointment
Intralesional or systemic corticosteroids and antibiotics
Leeches
Eponychial marsupialization
Excision of nailfold
Superficial low-dose radiotherapy
