Paronychia: Difference between revisions
 
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==Background==
==Background==
*Infection of lateral nail fold or perionychium
*Inflammation/infection of the proximal or lateral nail folds<ref name="Larios">Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008 Feb 1;77(3):339-46.</ref>
*Usually caused by minor trauma (e.g. nail-biting, manicures, hangnails)  
*Usually caused by direct or indirect minor trauma (e.g. nail-biting, manicures, hangnails, ingrown nail, dishwashing)
**Trauma allows entry of bacteria
**''[[S. aureus]]'' is most common, although ''[[S. pyogenes]]'', ''[[Pseudomonas pyocyanea]]'', and ''[[Proteus vulgaris]]'' are also common<ref name="Larios" />
**Can lead to distal phalanx [[osteomyelitis]] even if drained appropriately
 
{{Fingertip anatomy}}
 
==Clinical Features==
[[File:Paronychia.jpg|thumbnail|Paronychia of middle digit]]
[[File:Infectionofcutical.jpg|thumb|Paronychia as a secondary infection from a splinter.]]
*Rapid onset of erythema, edema, and pain of proximal or lateral nail folds<ref name="Larios" />
*Usually only affects one nail
*May see purulent drainage (expressed with pressure on nail)
 
==Differential Diagnosis==
{{Template:Hand Infection DDX}}
 
==Evaluation==
*Clinical diagnosis, based on history of minor trauma and physical examination
*If unclear if wound is fluctuant:
**Have patient apply pressure to distal aspect of affected digit
**A larger than expected area of blanching, reflecting a collection of pus, may identify need for drainage


==Management==
==Management==
*If no fluctuance is identified:
===Acute===
**Warm soaks, elevation
''More likely to be bacterial''
**TMP/SMX DS 1-2 tab PO x 7-10d + (cephalexin 500mg PO QID x7-10d OR dicloxacillin 500mg PO QID x 7–10d)
**Warm compresses, soaks, elevation
*If unclear if wound is fluctuant:
*[[Incision and drainage]], if fluctuance or purulence is present
**Have pt apply pressure to distal aspect of affected digit
**Consider soaking hand for preparation
**A larger than expected area of blanching, reflecting a collection of pus, may identify the need for drainage
**Consider [[digital block]]
*If fluctuance or pus is identified:
**Incise area of greatest fluctuance
***Incise parallel to nail (do NOT incise perpendicular to fluctulance)
***Use iris scissors, flat tweezers, or #11 blade
*[[Antibiotics]]
**Triple antibiotic ointment TID x 5-10 days (mild cases) ± [[topical steroid]]
**PO Antibiotics (more severe or persistent cases)<ref name="Larios" />
***[[Augmentin]] BID x 7 days '''OR'''
***[[Clindamycin]] 150-450mg TID or QID x 7 days '''OR'''
***[[TMP-SMX DS]] 1-2 tab PO BID x 7 days
 
===Chronic===
''Multifactorial inflammation due to persistent irritation; may also have fungal component<ref name="Larios" />''
*Mainstay of therapy is avoidance of irritant
*Consider topical antifungals vs Diflucan 150mg po qweek x 4-6 weeks
*Traditional treatments have been [[antifungals]], but accumulating evidence suggests chronic paronychia is eczematous<ref>Relhan V et al. Management of Chronic Paronychia. Indian J Dermatol. 2014 Jan-Feb; 59(1): 15–20.</ref>
**[[Topical steroids]] to start in ED, with follow up for possible systemic steroids with PCP should be considered
**Methylprednisolone aceponate cream 0.1%, over 3 weeks
**OR betamethasone 17-valerate 0.1% for 3 weeks


.18 After suppuration has occurred, the infection will exhibit either fluctuance or identifiable pus that will necessitate drainage. Minor infections can be treated with elevation of the perionychium or eponychium with a flat probe #11 blade (Figure 280-5) or needle slid along the surface of the nail.19 If only elevating the eponychium from the nail, this procedure can be performed without placing a digital block or providing analgesia.20 In general, only nonviable tissue can be incised without provoking pain.
==Disposition==
*Discharge


==See Also==
==See Also==
[[Hand Infection]]
*[[Hand and finger infections]]


==Source==
==References==
Tintinelli
<references/>


[[Category:ID]]
[[Category:ID]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Latest revision as of 18:12, 8 November 2023

Background

  • Inflammation/infection of the proximal or lateral nail folds[1]
  • Usually caused by direct or indirect minor trauma (e.g. nail-biting, manicures, hangnails, ingrown nail, dishwashing)

Nailtip Anatomy

A. Nail plate; B. lunula; C. root; D. sinus; E. matrix; F. nail bed; G. hyponychium; H. free margin.
  • The perionychium includes the nail bed and the paronychium.
  • The paronychium is the lateral nail fold (soft tissue lateral to the nail bed).
  • The hyponychium is the palmar surface skin distal to the nail.
  • The lunula is that white semi-moon shaped proximal portion of the nail.
  • The sterile matrix is deep to the nail, adheres to it and is distal to the lunule.
  • The germinal portion is proximal to the matrix and is responsible for nail growth.

Clinical Features

Paronychia of middle digit
Paronychia as a secondary infection from a splinter.
  • Rapid onset of erythema, edema, and pain of proximal or lateral nail folds[1]
  • Usually only affects one nail
  • May see purulent drainage (expressed with pressure on nail)

Differential Diagnosis

Hand and finger infections

Look-Alikes

Evaluation

  • Clinical diagnosis, based on history of minor trauma and physical examination
  • If unclear if wound is fluctuant:
    • Have patient apply pressure to distal aspect of affected digit
    • A larger than expected area of blanching, reflecting a collection of pus, may identify need for drainage

Management

Acute

More likely to be bacterial

    • Warm compresses, soaks, elevation
  • Incision and drainage, if fluctuance or purulence is present
    • Consider soaking hand for preparation
    • Consider digital block
    • Incise area of greatest fluctuance
      • Incise parallel to nail (do NOT incise perpendicular to fluctulance)
      • Use iris scissors, flat tweezers, or #11 blade
  • Antibiotics

Chronic

Multifactorial inflammation due to persistent irritation; may also have fungal component[1]

  • Mainstay of therapy is avoidance of irritant
  • Consider topical antifungals vs Diflucan 150mg po qweek x 4-6 weeks
  • Traditional treatments have been antifungals, but accumulating evidence suggests chronic paronychia is eczematous[2]
    • Topical steroids to start in ED, with follow up for possible systemic steroids with PCP should be considered
    • Methylprednisolone aceponate cream 0.1%, over 3 weeks
    • OR betamethasone 17-valerate 0.1% for 3 weeks

Disposition

  • Discharge

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008 Feb 1;77(3):339-46.
  2. ↑ Relhan V et al. Management of Chronic Paronychia. Indian J Dermatol. 2014 Jan-Feb; 59(1): 15–20.
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