Paronychia: acute and chronic (nail disease, felon/whitlow)

Are You Confident of the Diagnosis?

What you should be alert for in the history

Be alert for repeated excessive hand washing with water and certain soaps, detergents, and other chemicals, recurrent manicure or pedicure that destroyed or injured the nail folds, allergic contact dermatitis, or primary irritation due to certain nail polish or latex or excessive repeated habitual wet products.

Characteristic findings on physical examination

Acute: The clinical picture may be very variable but in principle there is redness, with or without pus (around the nail plate or beneath the nail bed), and swelling around the nail plates (usually lateral and or proximal nail folds) (Figure 1). Acute paronychia causes warmth and variable pain along the nail margin; mild pressure on the nail folds may provoke severe pain.

Chronic: Clinical features of chronic paronychia are similar to those associated with acute paronychia, but usually there is no pus accumulation (Figure 2). In the chronic phase there are several changes in the plate, such as thick, rough, ridges or other nail deformations.

Expected results of diagnostic studies

The dagnosis is usually determined by the clinical appearance. The histological feature is not specific, showing an acute or chronic nonspecific inflammatory process. Sometimes there is an abscess formation around the nail folds. Ultrasound and culture from purulent material will help to decide if and what systemic antibiotic should be given.

Diagnosis confirmation

The confirmation of the diagnosis is based on the clinical appearance and the clinical history of the paronychia.

Who is at Risk for Developing this Disease?

Risk factors for paronychia include:

Repeated excessive hand washing with water and certain soaps, detergents, and other chemicals

Injury to the nail folds mechanically or by sucking the fingernails

Recurrent manicure or pedicure that destroyed or injured the nail folds

Medications like vitamin A derivative (isotretionin, etretinate, etc)

Different chemotherapies that may lead to paronychia

Allergic contact dermatitis or primary irritation due to certain nail polish or latex or excessive repeated habitual wet products

Autoimmune diseases, such as psoriasis pemphigus vulgaris, scleroderma, lupus erythematosus, etc

Other diseases, such as diabetes mellitus, skin cancer

What is the Cause of the Disease?

Etiology

Since the different causes of (acute and chronic) paronychia are variable, the patient’s history regarding the paronychia is extremely important.

Acute paronychia: The major causative organism is Staphylococcus aureus. Less common organisms are Streptococcus species, Pseudomonas or Proteus spp.

Chronic paronychia: Causes include habitual hand washing, extensive manicure leading to destruction of the cuticle, which allows penetration of different irritant or allergic ingredients and/or different bacteria and/or yeast. Superimposed saprophytic fungi (Candida or molds spp.) should not be confused as pathogenic.

Pathophysiology

Acute paronychia: Acute dermatitis due to bacteria that penetrated just beneath to the proximal and/or lateral nail folds, causing inflamation that presents as swelling and redness, accompanied by a painful sensation. In severe cases, pus formation could develop.

Chronic paronychia: Repeated inflammatory processes due to different detergents causing chronic dermatitis, which results in swelling, redness and pain (all of which are less intense compared to the acute phase). Pus formation is uncommon.

Systemic Implications and Complications

Systemic implications and complications are rare but may include :

Abscess formation

Permanent deformation of the nail plate

Systemic fever/chills

Development of red streaks along the skin

Development of cellulitis or erysipelas

Joint pain

General ill feeling

Flu-like symptoms

Osteomyelitis

Flexor tenosynovitis

Treatment Options

Prevention

Prevention is key, especially in chronic paronychia. Recurrence of acute and/or chronic paronychia usually appears due to ignorance of the preventive regimen.

The recommended preventive regimen includes the following:

-Prevention of excessive hand and/or foot washing (excessive washing leads to destruction of the nail cuticles located around the nail plates). In the absence of the cuticle, different allergen and/or irritants and/or other infections such as bacteria and/or fungi such as yeast and/or molds may penetrate just beneath the lateral and/or proximal nail folds, causing paronychia.

-Cutting the nails and skin around the nail plates properly

-Not biting or picking the nails and /or the skin located around the nail plates (proximal and lateral nail folds)

-Avoidance of exposure of the nail plates and /or the lateral and proximal nail folds to different detergents and /or other irritants by using plastic gloves with gentle cotton lining.

– Never trim the cuticles !!!!! Removing the cuticles leads to the absence of protection beneath the lateral and proximal nail folds, causing paronychia.

-Trimming the nails properly, ie, not too deep (do not cut the nails too short)!

-The nails and their surroundings should be dry (wetness and humidity to the proximal and lateral nail folds may cause damage to the cuticles leading to a “port of entry”)

-Wearing vinyl gloves for wet work

-Refraining from the use of nail cosmetics until the disorder has been healed at least 1 month.

Medical treatment

The decision as to when to use topical and/or systemic treatment is based on to the severity and the cause of the paronychia, whether acute or chronic. Basically, the first step of the treatment of acute paronychia is based on the presence or absence of pus (abscess formation) in the proximal and/or lateral nail folds, just beneath the skin. In such cases the pus should be drained by skin incision. In deeper cases surgery should be performed. If the pus is located beneath the nail plate, the nail plate may be removed).

Usually, depending on the severity and the pathogenic cause(s) of the acute paronychia, a systemic antibiotic should be given to the patient against S.aureus (sometimes Streptococcus pyogenes or Pseudomonas aeruginosa causing the greenish-black in color beneath the nail plate, is the cause of the acute paronychia). Among the different systemic antibiotics that could be used are Flucloxacillin, 250mg 4 times daily for up to 10 days or Clindamycin, 300mg twice daily for 7-10 days.

In the cases of methicilin resistant S.aureus, systemic antibiotics such as trimethoprim/sulphamethoxazole (Resprim) should be given. In cases of Pseudomonas infections systemic anti-Gram-negative antibiotics such as Ofloxacin (Tarivid) 200mg twice daily for 7-10 days should be given. Surgical treatment may be recommended as monotherpay in mild cases. However in more severe cases surgical treatment is recommended with a combination of relevant antibiotics.

Surgical treatment

Surgical treatment may be recommended as monotherapy in mild cases. However in more severe cases surgical treatment is recommended with a combination of relevant antibiotics.

Optimal Therapeutic Approach for this Disease

The optimal treatment is different for acute verus chronic paronychia. For acute paronychia, optimal treatment is systemic/topical treatment or surgery. For chronic paronychia, optimal treatment is prevention and treatment of the chronic inflammation.

Patient Management

Patient management is based on the patient’s baseline condition. The more severe the paronychia, the more visits the patient will need. The caregiver will follow the improvement or worsening of the condition.If the paronychia becomes better, fewer follow-ups are needed. and vice versa. If there is no improvement after 3 days of treatment (or if the paronychia worsens) the caregiver will change or add different or adjuvant topical and/or systemic treatment(s). The follow-up period will take as long as the acute phase of the paronychia persists, after which the preventive regimen will be implemented.

Maintenance therapy is based on the preventive regimen previously discussed. The preventive treatment is very important, especially in those cases in which the cause is well known. If the treatment failed; that is, if the painful sensation, swelling, and redness are more severe than at baseline, (after several days of treatment) the patient should be checked again.

It may be that surgical intervention is needed, and/or that another systemic and/or topical treatment should be given. It should be stressed that in cases of abscess formation (beneath or around the nail) surgical involvement can give some relief but sometimes the pain from the surgical involvement itself can cause a painful sensation for several days. This should not be confused with worsening of the paronychia itself.

The patient and hisher family should know the natural history of the paronychia, and should be informed that in cases of surgical involvement the pain from the operation itself, or complication(s) such as another abscess, erysipelas/cellulitis sosteomyelitis (rare) bacteremia/ sepsis (very rare), could could occur due to the operation.

Unusual Clinical Scenarios to Consider in Patient Management

Surgical intervention can give some relief but sometimes the pain from the surgical involvement itself can cause a painful sensation for several days.

What is the Evidence?

Rigopoulos, D, Larios, G, Gregoriou, S, Alevizos, A. “Acute and chronic paronychia”. Am Fam Physician 2008 Feb . vol. 77. 1. pp. 339-46. (An excellent summation of how the patient should manage their condition in addition to therapeutic advice for the physician on how to approach the infectious and inflammatory nature of the condition, using antifungals and corticosteroids, respectively.)

Daniel CR 3rd, Iorizzo, M, Piraccini, BM, Tosti, A. “Grading simple chronic paronychia and onycholysis”. Int J Dermatol. vol. 45. 2006 Dec. pp. 1447-8. The following grading system for paronychia is proposed:
Stage I – some redness and swelling of the proximal and/or lateral nail folds causing disruption of the cuticle.
Stage II – pronounced redness and swelling of the proximal and/or lateral nail folds with disruption of the cuticle seal.
Stage III – redness, swelling of the proximal nail fold, no cuticle, some discomfort, some nail plate changes.
Stage IV – redness and swelling of the proximal nail fold, no cuticle, tender/painful, extensive nail plate changes.
Stage V – same as stage IV plus acute exacerbation (acute paronychia) of chronic paronychia.)

Daniel CR 3rd, Daniel, MP, Daniel, J, Sullivan, S, Bell, FE. “Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen”. Cutis. vol. 73. 2004 Jan. pp. 81-5. (Early results of a pilot study (N = 44) using ciclopirox 0.77% topical suspension in patients diagnosed with simple chronic paronychia and/or onycholysis show excellent therapeutic outcomes of a combined regimen of a broad-spectrum topical antifungal agent such as ciclopirox and contact-irritant avoidance in this patient population.)

Rockwell, PG. “Acute and chronic paronychia”. Am Fam Physician. vol. 63. 2001 Mar 15. pp. 1113-6. (Paronychia is one of the most common infections of the hand. Clinically, paronychia presents as an acute or a chronic condition. It is a localized, superficial infection or abscess of the paronychial tissues of the hands or, less commonly, the feet. Any disruption of the seal between the proximal nail fold and the nail plate can cause acute infections of the eponychial space by providing a portal of entry for bacteria. Treatment options for acute paronychias include warm-water soaks, oral antibiotic therapy and surgical drainage. In cases of chronic paronychia, it is important that the patient avoid possible irritants. Treatment options include the use of topical antifungal agents and steroids, and surgical intervention. Patients with chronic paronychias that are unresponsive to therapy should be checked for unusual causes, such as malignancy.)

Hochman, LG. “Paronychia: more than just an abscess”. Int J Dermatol.. vol. 34. 1995. pp. 385-386. (While acute paronychia may present as an abscess, chronic forms tend to be nonsuppurative and much more difficult to treat.

Baran, R, Barth, J, Dawber, RP. “Nail disorders: common presenting signs, differential diagnosis, and ireatment”. 1991. pp. 93-100. (This book discusses the differential diagnosis between different nail disorders. In the chapter that deals with paronychia, there is an emphasis on the clinical difference between acute and chronic paronychia. The chapter deals as well with the pathogenesis of chronic and acute paronychia.)

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