Paronychia

Background

Nailtip Anatomy
A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.
  • The perinychium includes the nail, the nailbed, and the surrounding tissue.
  • The paronychia is the lateral nail folds
  • The hyponychium is the palmar surface skin distal to the nail.
  • The lunula is that white semi-moon shaped proximal portion of the nail.
  • The sterile matrix is deep to the nail, adheres to it and is distal to the lunule.
  • The germinal portion is proximal to the matrix and is responsible for nail growth.
  • Inflammation/infection of the proximal or lateral nail folds[1]
  • Usually caused by direct or indirect minor trauma (e.g. nail-biting, manicures, hangnails, ingrown nail, dishwashing)
    • Trauma allows entry of bacteria
    • S. aureus is most common, although S. pyogenes, Pseudomonas pyocyanea, and Proteus vulgaris are also common[1]

Clinical Features
Paronychia of middle digit
Paronychia as a secondary infection from a splinter.
  • Rapid onset of erythema, edema, and pain of proximal or lateral nail folds[1]
  • Usually only affects one nail
  • May see purulent drainage (expressed with pressure on nail)

Differential Diagnosis

Hand and finger infections

Evaluation
  • Clinical diagnosis, based on history of minor trauma and physical examination
  • If unclear if wound is fluctuant:
    • Have patient apply pressure to distal aspect of affected digit
    • A larger than expected area of blanching, reflecting a collection of pus, may identify need for drainage

Management

Acute
  • More likely to be bacterial
  • If no fluctuance is identified:
    • Warm compresses, soaks, elevation
    • Antibiotic ointment TID x5-10 days (mild cases) ± topical steroid
    • PO Antibiotics (more severe or persistent cases)[1]
      • Augmentin BID x7 days OR
      • Clindamycin 150-450mg TID or QID x7 days OR
      • TMP-SMX DS 1-2 tab PO BID x7 days
  • If fluctuance or purulence is identified:
    • Consider soaking hand for preparation
    • Consider digital block
    • Incise area of greatest fluctuance
      • Incise parallel to nail (do NOT incise perpendicular to fluctulance)
      • Use iris scissors, flat tweezers, or #11 blade
    • Have patient continue warm soaks at home to prevent re-accumulation

Chronic
  • Multifactorial inflammation due to persistent irritation - may also have fungal component[1]
  • Mainstay of therapy is avoidance of irritant
  • Consider topical antifungals vs Diflucan 150mg po qweek x 4-6 weeks
  • Traditional treatments have been antifungals, but accumulating evidence suggests chronic paronychia is eczematous[2]
    • Topical steroids Rx to start in ED, with follow up for possible systemic steroids with PCP should be considered
    • Methylprednisolone aceponate cream 0.1%, over 3 weeks
    • OR betamethasone 17-valerate 0.1% for 3 weeks

Disposition
  • Discharge

See Also

References
  1. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008 Feb 1;77(3):339-46.
  2. Relhan V et al. Management of Chronic Paronychia. Indian J Dermatol. 2014 Jan-Feb; 59(1): 15–20.
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