Paronychia

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Basics

Description

  • Superficial inflammation of the lateral and posterior nail folds surrounding the fingernail or toenail
  • Acute: characterized by pain, erythema, and swelling lasting less than 6 weeks; usually a bacterial infection appearing after trauma. It can progress to abscess formation.
  • Chronic: characterized by swelling, tenderness, cuticle elevation, and nail dystrophy and separation lasting at least 6 weeks, or recurrent episodes of acute eponychial inflammation and drainage
  • May be considered work-related among bartenders, waitresses, nurses, and others who often wash their hands.
  • Usually involves one finger but drug-induced paronychia may involve multiple fingers
  • Relevant anatomy: nail bed, nail plate, and perionychium
  • Synonym(s): eponychia, perionychia

Pediatric Considerations
Less common in pediatric age groups. Thumb/finger-sucking is a risk factor (anaerobes and Escherichia coli may be present).

Epidemiology

Incidence
  • One of the most common hand infections in the United States
  • Predominant age: all ages
  • Predominant sex: female > male

Etiology and Pathophysiology

  • Acute: Staphylococcus aureus (1) most common and Streptococcus pyogenes (1); less frequently, Pseudomonas pyocyanea and Proteus vulgaris.
  • Chronic: eczematous reaction with secondary Candida albicans (~95%)
  • Pediatric age groups: mixed anaerobic and aerobic infections from oral flora (consider Eikenella corrodens, Fusobacterium, and Peptostreptococcus)
  • A paronychial infection commonly starts in the lateral nail fold.
  • Acute paronychia of the fingers is often due to trauma, and the toes is often due to ingrown toenails
  • Recurrent inflammation, persistent edema, and fibrosis of nail folds cause nail folds to round up and retract, exposing nail grooves to irritants, allergens, and pathogens.
  • Inflammation compromises ability of proximal nail fold to regenerate cuticle leading to decreased vascular supply. This can cause decrease efficacy of topical medications.
  • Early in the course, cellulitis alone may be present.
  • An abscess can form if the infection does not resolve quickly.

Risk Factors

  • Acute: direct or indirect trauma to cuticle or nail fold, manicured/sculptured nails, nail biting, thumb sucking, manipulating a hangnail
  • Chronic: frequent immersion of hands in water with excoriation of the lateral nail fold (e.g., chefs, bartenders, housekeepers, swimmers, dishwashers, nurses)
  • Predisposing conditions such as diabetes mellitus (DM) and immunosuppression
  • Medications such as EGFR inhibitors, systemic retinoids, chemotherapy and antiretroviral agents

General Prevention

  • Acute: Avoid trauma such as nail biting or manipulating a hangnail
  • Chronic: Avoid exposure to allergens and contact irritants; keep fingers/hands dry; wear rubber gloves with a cotton liner. Prevent excoriation of the skin.
  • Keep nails short.
  • Avoid manicures.
  • Apply moisturizer after washing hands.
  • Good glycemic control in diabetic patients

Commonly Associated Conditions

  • Diabetes mellitus
  • Eczema or atopic dermatitis
  • Immunosuppression

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Basics

Description

  • Superficial inflammation of the lateral and posterior nail folds surrounding the fingernail or toenail
  • Acute: characterized by pain, erythema, and swelling lasting less than 6 weeks; usually a bacterial infection appearing after trauma. It can progress to abscess formation.
  • Chronic: characterized by swelling, tenderness, cuticle elevation, and nail dystrophy and separation lasting at least 6 weeks, or recurrent episodes of acute eponychial inflammation and drainage
  • May be considered work-related among bartenders, waitresses, nurses, and others who often wash their hands.
  • Usually involves one finger but drug-induced paronychia may involve multiple fingers
  • Relevant anatomy: nail bed, nail plate, and perionychium
  • Synonym(s): eponychia, perionychia

Pediatric Considerations
Less common in pediatric age groups. Thumb/finger-sucking is a risk factor (anaerobes and Escherichia coli may be present).

Epidemiology

Incidence
  • One of the most common hand infections in the United States
  • Predominant age: all ages
  • Predominant sex: female > male

Etiology and Pathophysiology

  • Acute: Staphylococcus aureus (1) most common and Streptococcus pyogenes (1); less frequently, Pseudomonas pyocyanea and Proteus vulgaris.
  • Chronic: eczematous reaction with secondary Candida albicans (~95%)
  • Pediatric age groups: mixed anaerobic and aerobic infections from oral flora (consider Eikenella corrodens, Fusobacterium, and Peptostreptococcus)
  • A paronychial infection commonly starts in the lateral nail fold.
  • Acute paronychia of the fingers is often due to trauma, and the toes is often due to ingrown toenails
  • Recurrent inflammation, persistent edema, and fibrosis of nail folds cause nail folds to round up and retract, exposing nail grooves to irritants, allergens, and pathogens.
  • Inflammation compromises ability of proximal nail fold to regenerate cuticle leading to decreased vascular supply. This can cause decrease efficacy of topical medications.
  • Early in the course, cellulitis alone may be present.
  • An abscess can form if the infection does not resolve quickly.

Risk Factors

  • Acute: direct or indirect trauma to cuticle or nail fold, manicured/sculptured nails, nail biting, thumb sucking, manipulating a hangnail
  • Chronic: frequent immersion of hands in water with excoriation of the lateral nail fold (e.g., chefs, bartenders, housekeepers, swimmers, dishwashers, nurses)
  • Predisposing conditions such as diabetes mellitus (DM) and immunosuppression
  • Medications such as EGFR inhibitors, systemic retinoids, chemotherapy and antiretroviral agents

General Prevention

  • Acute: Avoid trauma such as nail biting or manipulating a hangnail
  • Chronic: Avoid exposure to allergens and contact irritants; keep fingers/hands dry; wear rubber gloves with a cotton liner. Prevent excoriation of the skin.
  • Keep nails short.
  • Avoid manicures.
  • Apply moisturizer after washing hands.
  • Good glycemic control in diabetic patients

Commonly Associated Conditions

  • Diabetes mellitus
  • Eczema or atopic dermatitis
  • Immunosuppression

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