Paronychia: Difference between revisions

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*Usually caused by direct or indirect minor trauma (e.g. nail-biting, manicures, hangnails, ingrown nail, dishwashing)
*Usually caused by direct or indirect minor trauma (e.g. nail-biting, manicures, hangnails, ingrown nail, dishwashing)
**Trauma allows entry of bacteria
**Trauma allows entry of bacteria
**''S. aureus'' is most common, although ''S. pyogenes'', ''Pseudomonas pyocyanea'', and ''Proteus vulgaris'' are also common<ref name="Larios" />
**''[[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


[[File:Paronychia.jpg|thumbnail|Paronychia of middle digit]]
{{Fingertip anatomy}}


==Clinical Features==
==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" />
*Rapid onset of erythema, edema, and pain of proximal or lateral nail folds<ref name="Larios" />
*Usually only affects one nail
*Usually only affects one nail
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{{Template:Hand Infection DDX}}
{{Template:Hand Infection DDX}}


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


==Treatment==
==Management==
===Acute===
===Acute===
*More likely to be bacterial
''More likely to be bacterial''
*If no fluctuance is identified:
**Warm compresses, soaks, elevation
**Warm compresses, soaks, elevation
**Antibiotic ointment TID x5-10 days (mild cases) ± topical steroid
*[[Incision and drainage]], if fluctuance or purulence is present
**PO Antibiotics (more severe or persistent cases)<ref name="Larios" />
***Augmentin BID x7 days '''OR'''
***Clindamycin 150-450mg TID or QID x7 days '''OR'''
***[[TMP-SMX DS]] 1-2 tab PO BID x7 days
*If fluctuance or purulence is identified:
**Consider soaking hand for preparation
**Consider soaking hand for preparation
**Consider [[digital block]]
**Consider [[digital block]]
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***Incise parallel to nail (do NOT incise perpendicular to fluctulance)  
***Incise parallel to nail (do NOT incise perpendicular to fluctulance)  
***Use iris scissors, flat tweezers, or #11 blade
***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===
===Chronic===
*Multifactorial inflammation due to persistent irritation - may also have fungal component<ref name="Larios" />
''Multifactorial inflammation due to persistent irritation; may also have fungal component<ref name="Larios" />''
*Mainstay of therapy is avoidance of irritant
*Mainstay of therapy is avoidance of irritant
*Consider topical antifungals vs Diflucan 150mg po qweek x 4-6 weeks
*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


==Disposition==
==Disposition==

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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