Paronychia

By admin On Oct 3, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Paronychia

Krystian Bigosinski

Basics

Description

Infectious inflammation of the folds of skin surrounding the fingernail or toenail; may be acute or chronic
System(s) affected: Skin/Exocrine
Genetics: No known genetic pattern
Synonym(s): Eponychia; Perionychia

Epidemiology

Incidence

Incidence/prevalence in U.S.: Common
Predominant age: All ages
Predominant gender: Female > Male (3:1)

Risk Factors

Acute: Trauma to skin surrounding nail, retained foreign body, ingrown nails
Chronic: Frequent immersion of hands in water, diabetes mellitus, artificial nail placement
May be considered work-related in bartenders, waitresses, nurses, and others who often wet their hands

General Prevention

Chronic: Avoid frequent wetting of hands. Wear rubber gloves with cloth liner.
Good diabetic control

Etiology

Acute: Staphylococcus aureus; less frequently, Streptococcus spp., Pseudomonas spp., and herpes simplex
Chronic: Candida albicans; less frequently, fungi—dermatophytes and, occasionally, molds (Scytalidium, Fusarium)

Commonly Associated Conditions

Diabetes mellitus

Diagnosis

Special tests: None
Diagnostic procedures: N/A

Physical Exam

Separation of nail fold from nail plate
Red, painful swelling of skin around nail plate
Purulent and fluctuant
Deformity of nail plate
Green changes in nail (Pseudomonas)

Diagnostic Tests & Interpretation

Lab

Gram stain
Culture and sensitivity
Potassium hydroxide preparation plus fungal culture
Drugs that may alter lab results: Use of OTC antimicrobials or antifungals

Differential Diagnosis

Herpetic whitlow
Felon
Reiter disease
Psoriasis

Treatment

Acute treatment: Outpatient
Long-term treatment

Medication

First Line

Acute (if diabetic, suppurative, or more severe cases):
- Amoxicillin-clavulanate 500–875 mg q12h
- Clindamycin 150–450 mg q6h
- Trimethoprim-sulfamethoxazole 160 mg/800 mg q12h
- Dicloxacillin 125–500 mg q6h
- Cloxacillin 250–500 mg q6h
- Erythromycin 500 mg q6h
- Cephalexin (Keflex) 250 mg q6h
Chronic:
- Bacterial: Mupirocin (Bactroban)
- Yeast or dermatophyte: Topical imidazoles (econazole, ketoconazole, terbinafine)

P.441

Systemic:
- Itraconazole (Sporanox) 200 mg/day × 90 days (may have longer action because incorporated in nail plate); pulse therapy may be useful: 200 mg b.i.d. × 7 days, repeated monthly for 2 mos
- Terbinafine (Lamisil) 250 mg/day × 90 days
- Fluconazole (Diflucan) 150 mg/wk × 4–6 mos
Viral (consider in wrestlers, rugby players): Acyclovir 400 mg q8h
Contraindications: Allergy to antibiotic
Precautions: Erythromycin may cause significant GI upset.
Significant possible interactions:
- Erythromycin affects levels of theophylline and effects of carbamazepine, digoxin, and corticosteroids. Cardiac toxicity is seen with terfenadine or astemizole.
- Ketoconazole, astemizole, itraconazole, fluconazole, terfenadine

Second Line

Antipseudomonal drugs, eg, 3rd-generation cephalosporin, aminoglycosides

Additional Treatment

General Measures

Acute: Warm compresses, protection of affected digit with splint
Chronic: Keep fingers dry.

Surgery/Other Procedures

Incision and drainage (I&D) of abscess, if present
If a subungual abscess or ingrown nail is present, will need partial or complete removal of nail

Ongoing Care

Follow-Up Recommendations

Full activity

Patient Monitoring

Routine follow-up until healed

Diet

No special diet

Patient Education

Chronic: Keep fingers dry.

Prognosis

With adequate treatment and prevention, healing can be expected.

Complications

Acute: Subungual abscess
Chronic: Secondary ridging, thickening, and discoloration of nail, nail loss

Additional Reading

Baran R, Dawber RPR, eds. Diseases of the nail and their management. 2nd Ed. Boston: Blackwell Scientific, 1994.

Brook I. Aerobic and anaerobic microbiology of paronychia. Ann Emerg Med. 1990;19:994–996.

Fitzpatrick TB, et al, eds. Dermatology in general medicine. 3rd Ed. New York: McGraw-Hill, 1987.

Hochman LG. Paronychia: more than just an abscess. Int J Dermatol. 1995;34:385–386.

Moschella SC, Hurley HJ, eds. Dermatology. 3rd Ed. Philadelphia: W.B. Saunders Co., 1992.

Pediatric Considerations

Anaerobes may be involved in patients with thumb/finger sucking.

Codes

ICD9

112.3 Candidiasis of skin and nails
681.02 Onychia and paronychia of finger