Chronic Paronychia

April 1, 2006

These patients have chronic paronychia. This inflammatory nail bed disorder is usually caused by prolonged exposure to wet environments and repeated minor cuticle trauma. Christopher Montoya, PA-C, of Beaverton, Ore, and Timothy R. Hurtado, DO, of Yongson, Korea, report that the nails of a 33-year-old man's right index finger and ring finger displayed multiple lateral grooves and edema near the eponychium.

 

These patients have chronic paronychia. This inflammatory nail bed disorder is usually caused by prolonged exposure to wet environments and repeated minor cuticle trauma. Christopher Montoya, PA-C, of Beaverton, Ore, and Timothy R. Hurtado, DO, of Yongson, Korea, report that the nails of a 33-year-old man's right index finger and ring finger displayed multiple lateral grooves and edema near the eponychium (A). These findings are characteristic of recurrent mycotic infection. Deep palpation of the fingernails elicited pain and purulent discharge. The patient, who was employed as a dishwasher, had had pain and swelling for more than 6 months. His infection responded to a weekly regimen of oral fluconazole in addition to topical clotrimazole, 1%, and triamcinolone, 0.025%, massaged into the cuticles twice daily; however, the nail defects remained, for the most part, unchanged. He was instructed to use rubber gloves at work and keep his hands dry.

Macerated cuticles allow irritants and microorganisms to invade the potential nail space. Staphylococcus aureus is the most common cause of acute exacerbations; Candida albicans is the most common isolate in chronic paronychia.1 Treatment consists of application of corticosteroid and antifungal creams until the lesions have resolved. Use of an oral antifungal agent may be beneficial in some patients.1 Recurrence is fairly common because of improper treatment or patient noncompliance. Prolonged infection can result in permanent nail dystrophy.

According to David M. Garzarelli, MD, of Pittsburgh, this 29-year-old man's ingrown toenail illustrates what can happen when chronic paronychia is left untreated (B). This patient's infection was accompanied by dermatitis. His infection resolved completely after extensive debridement of the great toe and application of an antifungal/corticosteroid cream.

In patients with painful swelling of a finger or toe, also consider a felon and herpetic whitlow in the differential diagnosis. A felon presents with marked pain and swelling in the distal finger pad and requires emergent incision and drainage to prevent complications. Herpetic whitlow presents with vesicles and is diagnosed with a Tzanck smear and viral culture; it does not require incision and drainage.

Dr Garzarelli notes that for patients with chronic paronychia who have erythema and swelling, separation of the cuticle from the lateral nail fold and draining of the abscess may be all that is required. A digital nerve block using a local anesthetic alone, without epinephrine, may be necessary for more extensive debridement.

References:

REFERENCE:


1.

Fitzpatrick TB, Johnson RA, Wolff K, et al. Infections of the nail apparatus. In:

Color Atlas & Synopsis of Clinical Dermatology: Common & Serious Diseases.

4th ed. New York: McGraw-Hill; 2001:958.