Acute Paronychia

Aka: Acute Paronychia, Paronychia, Perionychia

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II. Definitions

  1. Paronychia
    1. Superficial infection of distal phalanx along nail edge (nail fold)
    2. Affects perionychium (Epidermis at nail border)
  2. Acute Paronychia
    1. Typically infection-mediated Paronychia of a single digit lasting <6 weeks
  3. Chronic Paronychia
    1. Typically irritant-mediated Paronychia of multiple digits lasting >6 weeks

III. Epidemiology

  1. More common in women (by 3 fold)

IV. Pathophysiology

  1. Disrupted seal between nail fold and nail plate
  2. Mechanisms of Acute Paronychia
    1. Local Penetrating Trauma
    2. Nail biting
    3. Finger sucking
    4. Aggressive manicure
    5. Ingrown Nails
    6. Hang nail (esp. if manipulated)
    7. Artificial nail placement (sculptured nails)
    8. Dermatitis (e.g. Pemphigus Vulgaris, Psoriasis, Eczematous Dermatitis, Irritant Contact Dermatitis)
    9. Occupational Trauma (e.g. bartenders, dish washers)

V. Etiology: Polymicrobial in many cases

  1. Trauma related (most common)
    1. Staphylococcus aureus (common)
  2. Oral flora related from nail biting or sucking
    1. Streptococcus Pyogenes (common)
    2. Pseudomonas pyocyanea
    3. Gram Negative Bacteria (e.g. Proteus vulgaris)
  3. Other causes (oral Anaerobes, esp. Diabetes Mellitus, injection drug use)
    1. Bacteroides
    2. Fusobacterium nucleatum

VI. Symptoms

  1. Onset 2-5 days after Trauma
  2. Local pain at perionychium (Eponychium)

VII. Signs

  1. Distribution
    1. Single digit involvement (esp. fingers) is typical for Acute Paronychia
  2. Early: Perionychial inflammation
    1. Local redness
    2. Swelling
    3. Tenderness at nail edge to palpation
    4. Discolored nail
  3. Late: Complicated infection
    1. Abscess at perionychium (appears pale, white at distended paronychium)
    2. Nail bed infection
    3. May elevate nail plate

VIII. Signs: Digital Pressure Test

  1. Indication
    1. Diagnostic for early Paronychia with abscess before abscess is clearly demarcated
  2. Technique
    1. Patient opposes thumb and affected finger (applying pressure to pulp on volar aspect at finger tip)
  3. Positive test
    1. Abscess becomes demarcated with blanching
  4. Reference
    1. Turkmen (2004) Br J Plast Surg 57:93-4 [PubMed]

IX. Precautions

  1. Acute Paronychia typically involves only a single digit (unlike Chronic Paronychia which involves multiple)
    1. Consider systemic conditions when Acute Paronychia involves multiple digits

X. Differential Diagnosis

  1. See Hand Infection
  2. Chronic Paronychia
  3. Felon (finger pad or pulp infection)
  4. Eczematous Dermatitis
  5. Herpetic Whitlow
  6. Cellulitis
  7. Tuft Fracture
  8. Psoriasis
  9. Dermatomyositis
  10. Granuloma Annulare
  11. Pyogenic Granuloma
  12. Reiter Syndrome
  13. Contact Dermatitis
  14. Maceration from excessive moisture
  15. Ingrown Toenail
  16. Melanoma
  17. Squamous Cell Skin Cancer
  18. Pemphigus Vulgaris

XI. Labs

  1. Avoid wound cultures (poor yield)

XII. Imaging

  1. Bedside Soft-Tissue Ultrasound
    1. May define abscess or deep space infection

XIII. Management: Incision and Drainage

  1. Anesthesia
    1. Digital Block (Metacarpal Block) or
    2. Wing Block
  2. Contraindications
    1. Herpetic Whitlow
  3. Technique 1
    1. Often performed without Digital Block (blanched Paronychia roof is often without Sensation)
    2. Identify blanched skin over abscess (may use digital pressure test as above)
    3. Puncture abscess with #18 gauge needle in multiple sites to allow drainage
      1. Sliding the needle tip horizontally at the puncture site can enlarge the puncture and allow greater drainage
  4. Technique 2
    1. Digital BlockAnesthesia is required
    2. Pass #15 or #11 scalpel blade passed between nail and nail fold
      1. Abscess area should be clearly demarcated by overlying blanching of skin
      2. Direct blade away from nail
      3. Avoid entering through the Eponychium
      4. Avoid injury to cuticle
    3. May need to remove part of nail (or perform Nail Trephination) to expose subungual infection
      1. Indicated for subungual abscess
    4. Irrigate wound
    5. Larger wounds could be packed with small plain gauze
  5. Other measures
    1. Wound culture not indicated (poor yield)
  6. Post-procedure care
    1. Warm water soaks (or Burrows Soluition or acetic acid 1:1 dilution) 2-3 times daily for 3 days
    2. Topical and oral antibiotics are not typically needed after Incision and Drainage
      1. Exceptions include significant Cellulitis, Immunocompromised state

XIV. Management: General Measures

  1. Soak 3-4 times daily for 15 minutes each
    1. Warm water or
    2. Burow's Solution (aluminum acetate) or
    3. Acetic acid soaks (1:1 vinegar in water)
  2. Splint affected finger
  3. Tetanus Prophylaxis
  4. Incision and Drainage
    1. Indicated if abscess pocket is delineated (see below)
  5. Antibiotics: Topical in early, mild cases
    1. Bactroban twice daily for 5-10 days or
    2. Gentamicin ointment three times daily for 5-10 days
    3. Topical Fluoroquinolone
      1. Indicated for suspected Pseudomonas infection (green discoloration, moist environment)
    4. Neomycin ointment
      1. Has been used in the past for pseudomonal Paronychia
      2. Higher risk of Allergic Reaction (10%) and generally avoided
    5. Consider with adjunctive Topical Corticosteroid (medium to high potency)
      1. Speeds healing time
      2. Wollina (2001) J Eur Acad Dermatol Venereol 15:82-4 [PubMed]
  6. Antibiotics: Systemic in persistent, moderate to severe cases with associated Cellulitis
    1. Antibiotics are not typically needed after Incision and Drainage
      1. Limit to Immunocompromised patients or with severe infections and ill appearing patients
    2. History may direct specific antibiotics
      1. Traumatic cause in region where MRSA is common
      2. Nail biting cause directs antibiotic coverage for oral flora
      3. Green discoloration (esp repeat Trauma in chronically moist environments) may direct Pseudomonas coverage
    3. First line (for Staphylococcus aureus if Trauma is source as opposed to oral flora)
      1. Cephalexin (Keflex)
      2. Dicloxacillin
    4. Second Line: MRSA suspected
      1. Trimethoprim Sulfamethoxazole (Septra)
      2. Doxycycline
    5. Second Line (for Gram Negatives and Anaerobes if oral flora source suspected)
      1. Clindamycin
      2. Amoxicillin-Clavulanate (Augmentin)
      3. Trimethoprim Sulfamethoxazole (Septra)
      4. Fluoroquinolones (e.g. Ciprofloxacin)
    6. Pseudomonas coverage (green discharge)
      1. Ciprofloxacin

XV. Prevention

  1. Avoid nail Trauma from nail biting, picking or sucking
  2. Do not trim or remove cuticles
  3. Keep finger nails clean and dry, and keep nails short
  4. Apply Moisturizing Lotion after Hand Washing
  5. Optimize Glucose control in Diabetes Mellitus
  6. Avoid recurrent prolonged exposure to moisture and causes of contact irritant dermatitis
    1. Consider Rubber gloves (and cotton liners) when working in moist environments (e.g. dish washing)

XVI. Complications

  1. Chronic Paronychia (from recurrent Acute Paronychia)

XVII. References

  1. Warrington (2023) Crit Dec Emerg Med 37(6): 23
  2. Brook (1990) Ann Emerg Med 19:994-6 [PubMed]
  3. Hochman (1995) Int J Dermatol 34:385-6 [PubMed]
  4. Jebson (1998) Hand Clin 14:547-55 [PubMed]
  5. Leggit (2017) Am Fam Physician 96(1): 44-51 [PubMed]
  6. Rerucha (2019) Am Fam Physician 99(4):228-36 [PubMed]
  7. Rigopoulos (2008) Am Fam Physician 77:339-48 [PubMed]
  8. Rockwell (2001) Am Fam Physician 63(6): 113-6 [PubMed]

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