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Paronychia is one of the most common infections of the hand. Clinically, paronychia
presents as an acute or a chronic condition. It is a localized, superficial infection or
abscess of the paronychial tissues of the hands or, less commonly, the feet. Any dis-
ruption of the seal between the proximal nail fold and the nail plate can cause acute
infections of the eponychial space by providing a portal of entry for bacteria. Treat-
ment options for acute paronychias include warm-water soaks, oral antibiotic therapy
and surgical drainage. In cases of chronic paronychia, it is important that the patient
avoid possible irritants. Treatment options include the use of topical antifungal agents
and steroids, and surgical intervention. Patients with chronic paronychias that are
unresponsive to therapy should be checked for unusual causes, such as malignancy.
(Am Fam Physician 2001;63:1113-6.)
P
Members of various aronychia is one of the most tion of most of the nail volume, and the ster-
medical faculties common infections of the hand. ile matrix. This matrix is the “root” of the
develop articles for
“Practical Therapeu-
Paronychias are localized, super- nail, and its distal portion is visible on some
tics.” This article is one ficial infections or abscesses of nails as the half-moon–shaped structure
in a series coordinated the perionychium (epidermis called the lunula.1 The nail plate is hard and
by the Department of bordering the nails). Paronychial infections translucent, and is composed of dead ker-
Family Medicine at the develop when a disruption occurs between atin.2 The plate is surrounded by the periony-
University of Michigan
Medical School, Ann
the seal of the proximal nail fold and the nail chium, which consists of proximal and lateral
Arbor. Guest editor of plate that allows a portal of entry for invading nail folds, and the hyponychium, the area
the series is Barbara S. organisms. beneath the free edge of the nail1 (Figure 1).
Apgar, M.D., M.S., Noninfectious causes of paronychia
who is also an associ- include contact irritants and excessive mois- Acute Paronychia
ate editor of AFP.
ture. Clinically, paronychia presents as an Acute paronychia most commonly results
acute or chronic (longer than six weeks’ from nail biting, finger sucking, aggressive
duration) condition. People with occupa- manicuring, a hang nail or penetrating
tions such as baker, bartender and dish- trauma, with or without retained foreign
washer seem predisposed to developing body 3 (Figure 2). Sculptured fingernail (artifi-
chronic paronychia. Treatment may consist cial nail) placement has also been shown to be
of warm-water soaks, antimicrobial therapy associated with the development of parony-
or surgical intervention. chia.4 The most common infecting organism
Nail Anatomy
Components of the nail complex include Pus beneath eponychial fold Eponychium
the nail bed (matrix), the nail plate and the
perionychium. The nail bed lies beneath the Nail
nail plate and contains the blood vessels and
. .. ...
ILLUSTRATIONS BY RENEE L. CANNON
MARCH 15, 2001 / VOLUME 63, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1113
is Staphylococcus aureus, followed by strepto-
cocci and pseudomonas organisms. Gram-
negative organisms, herpes simplex virus,
dermatophytes and yeasts have also been
reported as causative agents. Children are
prone to acute paronychia through direct
inoculation of fingers with flora from the
mouth secondary to finger sucking and nail
biting. This scenario is similar to the acquisi-
tion of infectious organisms following
human bites or clenched-fist injuries.5
CLINICAL PRESENTATION
FIGURE 2. Acute paronychia.
Patients with acute paronychia may report
localized pain and tenderness of the periony-
chium. Symptoms may arise spontaneously, may develop as an abscess around the peri-
or following trauma or manipulation of the onychium. Fluctuance and local purulence at
nail bed. The perionychial area usually ap- the nail margin may occur, and infection
pears erythematous and inflamed, and the may extend beneath the nail margin to
nail may appear discolored and even dis- involve the nail bed. Such an accumulation of
torted. If left untreated, a collection of pus pus can produce elevation of the nail plate
(Table 1).6
TREATMENT
TABLE 1
Comparison of Acute and Chronic Paronychia Conservative treatment, such as warm-
water soaks three to four times a day, may be
Features Acute Chronic effective early in the course if an abscess has
not formed.3 If infection persists, warm soaks
Clinical Red, hot, tender nail folds, Swollen, tender, red (not in addition to an oral antistaphylococcal agent
appearance with or without abscess as red as acute), boggy
nail fold; fluctuance rare
and splint protection of the affected part are
indicated. Children who suck their fingers and
People at People who bite nails, suck People repeatedly exposed
high risk fingers, experience nail to water or irritants (e.g.,
patients who bite their nails should be treated
trauma (manicures) bartenders, housekeepers, against anaerobes with antibiotic therapy.
dishwashers) Penicillin and ampicillin are the most effective
Pathogens Staphylococcal aureus, Candida albicans (95 percent), agents against oral bacteria. However, S.
streptococci, Pseudomonas, atypical mycobacteria, aureus and Bacteroides can be resistant to
anaerobes gram-negative rods these antibiotics. Clindamycin (Cleocin) and
Treatment Warm soaks, oral antibiotics Avoidance of water and the combination of amoxicillin–clavulanate
(clindamycin [Cleocin] or irritating substances; use of potassium (Augmentin) are effective against
amoxicillin–clavulanate topical steroids and most pathogens isolated from these infec-
potassium [Augmentin]); antifungal agents; surgery
spontaneous drainage, if as last resort
tions.5,7 First-generation cephalosporins are
possible; surgical incision not as effective because of resistance of some
and drainage anaerobic bacteria and Escherichia coli.5 Some
authorities recommend that aerobic and
Information from Jebson PJ. Infections of the fingertip. Paronychias and felons. anaerobic cultures be obtained from serious
Hand Clin 1998;14:547-55. paronychial infections before antimicrobial
therapy is initiated.5
1114 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 6 / MARCH 15, 2001
Paronychia
MARCH 15, 2001 / VOLUME 63, NUMBER 6 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1115
Paronychia
CLINICAL PRESENTATION
Chronic paronychia usually causes swollen,
red, tender and boggy nail folds (Figure 4).
Symptoms are classically present for six weeks
or longer.11 Fluctuance is rare, and there is less
erythema than is present in acute paronychia.
Inflammation, pain and swelling may occur
episodically, often after exposure to water or a FIGURE 4. Chronic paronychia.
moist environment. Eventually, the nail plates
become thickened and discolored, with pro- potential secondary bacterial infections with
nounced transverse ridges.6,8 The cuticles and antibacterial solutions or ointments, acetic
nail folds may separate from the nail plate, acid soaks (1:1 ratio of vinegar to water) or
forming a space for various microbes, espe- oral antibiotics may be necessary. Surgical
cially Candida albicans, to invade.8 A wet intervention is indicated when medical treat-
mount with potassium hydroxide from a ment fails. Excellent results have been
scraping may show hyphae, or a culture of the reported with the use of an eponychial marsu-
purulent discharge may show hyphae for bac- pialization technique, as well as removal of the
teria and fungal elements. C. albicans may be entire nail and application of an antifungal-
cultured from 95 percent of cases of chronic steroid ointment to the nail bed.3,6,8
paronychia.6 Other pathogens, including In patients with a chronic paronychia that is
atypical mycobacteria, gram-negative rods unresponsive to therapy, unusual and poten-
and gram-negative cocci, have also been tially serious causes of abnormal nail and skin
implicated in chronic paronychia (Table 1).6 appearance, such as malignancy, should be
explored.3,10
TREATMENT
Treatment of chronic paronychia primarily REFERENCES
involves avoiding predisposing factors such as 1. Rich P. Nail disorders. Diagnosis and treatment of
exposure to irritating substances, prolonged infectious, inflammatory, and neoplastic nail condi-
exposure to water, manicures, nail trauma and tions. Med Clin North Am 1998;82:1171-83,vii.
2. Habif TP. Clinical dermatology: a color guide to diag-
finger sucking. When it is necessary to wear nosis and therapy. 3d ed. St. Louis: Mosby, 1996.
vinyl gloves, cotton gloves should be worn 3. Hochman LG. Paronychia: more than just an
underneath.3,10 Treatment with a combination abscess. Int J Dermatol 1995;34:385-6.
4. Roberge RJ, Weinstein D, Thimons MM. Periony-
of topical steroids and an antifungal agent has chial infections associated with sculptured nails.
been shown to be successful.3,7 Oral antifungal Am J Emerg Med 1999;17:581-2.
therapy is rarely necesssary.3 Treatment of 5. Brook I. Aerobic and anaerobic microbiology of
paronychia. Ann Emerg Med 1990;19:994-6.
6. Jebson PJ. Infections of the fingertip. Paronychias
and felons. Hand Clin 1998;14:547-55,viii.
7. Brook I. Paronychia: a mixed infection. Microbiology
The Author and management. J Hand Surg [Br] 1993;18:358-9.
PAMELA G. ROCKWELL, D.O., is clinical assistant professor in the Department of Fam- 8. Canales FL, Newmeyer WL 3d, Kilgore ES. The
ily Medicine at the University of Michigan Medical School, Ann Arbor. Dr. Rockwell also treatment of felons and paronychias. Hand Clin
serves as the medical director of the Family Practice Clinic at East Ann Arbor Health 1989;5:515-23.
Center in Ann Arbor, which is affiliated with the University of Michigan Medical 9. Lee TC. The office treatment of simple paronychias
School. She received a medical degree from Michigan State University College of and ganglions. Med Times 1981;109:49-51,54-5.
Osteopathic Medicine in East Lansing and completed a family practice residency at 10. Jules KT, Bonar PL. Nail infections. Clin Podiatr Med
Eastern Virginia Medical School in Norfolk, Va. Surg 1989;6:403-16.
11. Daniel CR 3d, Daniel MP, Daniel CM, Sullivan S,
Address correspondence to Pamela G. Rockwell, D.O., 4260 Plymouth Rd., Ann Arbor, Ellis G. Chronic paronychia and onycholysis: a thir-
MI 48109 (e-mail: prockwel@umich.edu). Reprints are not available from the author. teen-year experience. Cutis 1996;58:397-401.
1116 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 63, NUMBER 6 / MARCH 15, 2001