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Paronychia
is infection of the periungual tissues.
Paronychia is usually acute, but chronic cases occur. In acute paronychia, the causative organisms are usually Staphylococcus aureus or streptococci, less commonly Pseudomonas or Proteus spp. Organisms enter through a break in the epidermis resulting from a hangnail, trauma to a nail fold, loss of the cuticle, or chronic irritation (eg, from water and detergents). Paronychia is more common in people who bite or suck their fingers. In toes, infection often begins at an ingrown toenail. In diabetics and those with peripheral vascular disease, toe paronychia can threaten the limb.
Symptoms and Signs
Paronychia develops along the nail margin (lateral and proximal nail folds), manifesting over hours to days with pain, warmth, redness, and swelling. Pus usually develops along the nail margin and sometimes beneath the nail. Rarely, infection penetrates deep into the finger, sometimes producing infectious flexor tenosynovitis. In diabetics and others with peripheral vascular disease, toe paronychia should be monitored for signs of cellulitis or more severe infection (eg, extension of edema or erythema, lymphadenopathy, fever).
Diagnosis
and Treatment
Diagnosis is by inspection. Early treatment is warm compresses or soaks and an antistaphylococcal antibiotic (eg, dicloxacillin or cephalexin 250 mg po qid, clindamycin 300 mg po qid). Fluctuant swelling or visible pus should be drained with a Freer elevator, small hemostat, or #11 scalpel blade inserted between the nail and nail fold. Skin incision is unnecessary. A thin gauze wick should be inserted for 24 to 48 h to allow drainage.
Chronic Paronychia
Chronic paronychia
is recurrent or persistent nail fold inflammation, typically of
the fingers.
Chronic paronychia occurs almost always in people whose hands are chronically wet (eg, dishwashers, bartenders, housekeepers), particularly if diabetic or immunocompromised. Candida is often present, but its role in etiology is unclear; fungal eradication does not always resolve the condition. The condition may be an irritant dermatitis with secondary fungal colonization.
The nail fold is painful and red as in acute paronychia, but there is almost never pus accumulation. Eventually, there is loss of the cuticle and separation of the nail fold from the nail plate. This forms a space which allows entry of irritants and microorganisms. The nail becomes distorted.
Diagnosis is clinical. Primary treatment is to keep the hands dry and to assist the cuticle in reforming to close the space between the nail fold and nail plate. Gloves or barrier creams are used if water contact is necessary. Topical corticosteroids may be helpful. Antifungal treatments are helpful only in reducing colonizing fungal organisms. Thymol 3% in ethanol applied several times a day to the space left by loss of cuticle aids in keeping this space dry and free of microorganisms.
Last full review/revision November 2005
Content last modified November 2005
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