Updated: 10/4/2016

Paronychia

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Introduction
  • A soft tissue infection of the proximal or lateral nail fold
  • Epidemiology
    • incidence
      • most common hand infection (one third of all hand infections)
    • demographics
      • usually in children
      • more common in women (3:1)
    • location
      • most commonly involve the thumb
  • 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
Differentials
  • 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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