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Paronychia

Maladywise

SUMMARY: Overview of paronychia aka angry fingernails and toenails due to inflammation.

Definition

Inflammation of the folds of tissue surrounding the nail of a toe or finger.

Fact Sheet

Predisposing factors

  • Overzealous manicuring

  • Nail biting, picking, sucking

  • Ingrown nail

  • Diabetes Mellitus

  • Occupations where your hands are constantly immersed in water

  • Medication side effects

Acute Paronychia (<6 weeks)

Causes

  • Infection by skin flora (staph aureus, strep pyogenes)

  • Drugs (chemotherapy, immunotherapy, anti-virals)

  • Trauma (Splinter, nail-biting, picking, manicures)

Presentation

Acute paronychia is characterised by the rapid onset of painful redness and swelling of the nail folds. Often happens two to five days after minor local trauma. Usually, only involves one finger.

Differential Diagnoses

  • Felon (infection of the finger pulp space, not nail folds)

  • Herpes simplex infection

  • Acrodermatitis continua of Hallopeau (form of pustular psoriasis)

  • Onychomycosis (fungal infection)

  • Green nail syndrome (bacterial infection with Pseudomonas Aeruginosa)

Treatment of Acute Paronychia

If there is an associated abscess

  • Incision and drainage with purulent discharge cultured

  • Reassess in 7 days

  • In ongoing inflammation then systemic antibiotic therapy (Flucloxacillin or Cephalexin)

If there is no abscess

  • Warm water or antiseptic soaks for 10 to 15 minutes (eg, chlorhexidine, povidone-iodine)

  • Topical antibiotics for 3 times daily (Mupirocin 2%)

  • Reassess in 7 days

  • If ongoing inflammation then systemic antibiotic therapy

Long-term prevention

  • Avoid aggressive manicuring

  • Avoid nail biting and picking at hangnails

Chronic Paronychia (>6 weeks)

Causes

  • Environment irritations and allergens (e.g. wet work, foods, chemicals)

  • Inflammatory skin conditions such as dermatitis and psoriasis

  • Secondary fungal or bacterial infection can occur

Clinical Presentation

There is usually swelling and redness of the nail folds with loss of cuticle. Nail changes can occur such as ridging, Beau lines, and discolouration.

Differential Diagnosis

  • Squamous cell carcinoma

  • Can be an external manifestation of internal cancers

  • Psoriasis

  • Reiter’s Syndrome

Treatment

  • Avoid environmental triggers

  • Keep hands as dry as possible

  • Use gloves for any wet work

Medication

First-line therapy is topical corticosteroids

  • High potency steroid (e.g. Diprosone, Advantan) used once or twice daily for two to four weeks

References