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Updated: May 15 2021


  • Summary
    • Paronychias are soft tissue infections of the proximal or lateral nail fold.
    • Diagnosis involves careful clinical examination assessing for erythema and fluctuance around the nail with discoloration/hypertrophic changes of the nail.
    • Treatment involves warm soaks and oral antibiotics and if fluctuance is present, debridement and partial/complete nail removal is warranted.
  • Epidemiology
    • Incidence
      • most common hand infection (one third of all hand infections)
    • Demographics
      • usually in children
      • more common in women (3:1)
    • Anatomic location
      • most commonly involve the thumb
  • Etiology
    • Pathophysiology
      • organism
        • acute infection
          • adults - usually caused by Staphylococcus aureus
          • children - usually mixed oropharyngeal flora
          • diabetics - mixed bacterial infection
        • chronic infection
          • Candida albicans (more common in diabetics)
          • often unresponsive to antibiotics
  • Classification
    • Acute paronychia
      • minor trauma from nail biting, thumb sucking, manicure
    • Chronic paronychia
      • occupations with prolonged exposure to water and irritant acid/alkali chemicalse.g. dishwashers, florists, gardeners, housekeepers, swimmers, bartenders
      • risk factors for chronic paronychia
        • diabetes
        • psoriasis
        • steroids
        • retroviral drugs (indinavir and lamivudine)
          • indinavir is most common cause of paronychia in HIV positive patients
          • resolves when medication is discontinued
  • Anatomy
    • Nail organ
      • adds to stability of finger tip by acting as counterforce to finger pulp
      • thermoregulation (glomus bodies of nail bed and nail matrix)
      • allows "extended precision grip" (using opposed thumbnail and index fingernail to pluck out a splinter)
    • Nail plate
      • made of keratin, grows at 3mm/month, faster in summer
      • fingernails grow faster than toenails (fingernails take 3-6 months to regrow, and toenails take 12-18 months)
      • growing part is under proximal eponychium
    • Perionychium
      • comprises hyponychium, eponychium and paronychium
  • Presentation
    • Symptoms
      • acute paronychia
        • pain and
        • nail fold tenderness
        • erythema
        • swelling
      • chronic paronychia
        • recurrent bouts of low-grade inflammation (less severe than acute paronychia)
    • Physical exam
      • acute paronychia
        • fluctuance
        • nail plate discoloration (green discoloration suggests Pseudomonas)
      • chronic paronychia
        • nail plate hypertrophy (fungal infection)
        • nail fold blunting and retraction after repeated bouts of inflammation
        • prominent transverse ridges on nail plate
  • Differential
    • Herpetic whitlow 
    • Felon
    • Onychomycosis
    • Psoriasis
    • Glomus tumor
    • Mucous cyst
  • Treatment
    • Acute paronychia
      • nonoperative
        • warm soaks, oral antibiotics and avoidance of nail biting
          • indications
            • swelling only, but no fluctuance
          • medications
            • augmentin or clindamycin
      • operative
        • I&D with partial or total nail bed removal followed by oral abx
          • indications
            • fluctuance (indicates abscess collection)
            • nail bed mobility (indicates tracking under the nail)
          • follow with oral antibiotics and routine dressing change
    • Chronic paronychia
      • nonoperative
        • warm soaks, avoidance of finger sucking, topical antifungals
          • indications
            • first line of treatment
          • medications
            • miconazole is commonly used
      • operative
        • marsupialization (excision of dorsal eponychium down to level of germinal matrix)
          • indications
            • severe cases that fail nonoperative treatment
        • technique
          • combine with nail plate removal
          • leave to heal by secondary intention
  • Techniques
    • I&D with partial or total nail bed removal
      • approach
        • may be done in emergency room
        • incision into sulcus between lateral nail plate and lateral nail fold
      • technique
        • preserve eponychial fold by placing materials (removed nail) between skin and nail bed
        • if abscess extends proximally over eponychium (eponychia), a separate counterincision is needed over the eponychium
        • obtain gram stain and culture
  • Complications
    • Eponychia
      • spread into eponychium
    • Runaround infection
      • involvement of both lateral nail folds
    • Felon
      • spread volarward to pulp space
      • I&D of finger pulp is necessary
    • Flexor tenosynovitis
      • volar spread into flexor sheath
    • Subungual abscess ("floating nail")
      • nail plate removal is necessary
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