Paronychia

Paronychia is an infection and inflammation of the peri-ungual tissues (skin surrounding the nail plate), particularly the proximal or lateral nail folds.

It is one of the most common nail disorders seen in clinical practice and occurs when the protective barrier between the nail plate and nail fold is disrupted, allowing microorganisms to enter.

There are two major forms:

Etiology

Acute Paronychia (Bacterial)

Occurs after trauma to nail fold such as:

• Nail biting

• Aggressive manicuring

• Hangnails

• Artificial nails

• Finger sucking (children)

• Occupational injury

Common organisms

• Staphylococcus aureus (most common)

• Streptococcus species

• Gram-negative organisms (rare)

Chronic Paronychia (Fungal/Mixed)

Occurs due to repeated moisture exposure causing cuticle destruction.

Risk groups

• Housewives

• Healthcare workers

• Bartenders

• Food handlers

• Fishermen

• Diabetics

Common organisms

• Candida albicans

• Mixed bacterial flora

Pathophysiology

Normal protection:Cuticle forms a seal preventing microbial entry.

When damaged:

1. Moisture penetrates nail fold

2. Cuticle separates from nail plate

3. Microbes colonize nail groove

4. Persistent inflammation occurs

Acute → pus formationChronic → inflammatory fibrosis and dystrophy

Clinical Features

A. Acute Paronychia

Early Stage

• Painful throbbing nail

• Redness around nail fold

• Swelling

• Warmth

• Tenderness

Late Stage

• Fluctuant abscess

• Pus discharge

• Severe pressure pain

• Fever (rare)

B. Chronic Paronychia

• Swollen nail folds

• Loss of cuticle

• Minimal pain

• Intermittent redness

• Nail ridging

• Thickened dystrophic nail

• Discoloration

• Recurrent exacerbations

Diagnostic Criteria

Diagnosis is clinical when the following are present:

Acute

• Sudden painful swelling around nail

• Erythema

• Tenderness

• Possible pus collection

Chronic

• Symptoms >6 weeks

• Absent cuticle

• Nail dystrophy

• Mild inflammation

Investigations

Usually not required, but may be done in complicated cases.

Differential Diagnosis

• Herpetic whitlow

• Felon (deep pulp infection)

• Nail psoriasis

• Onychomycosis

• Ingrown toenail

• Contact dermatitis

Treatment

Management depends on acute vs chronic disease.

A. Non-Pharmacological Treatment

Acute

• Warm saline soaks 3–4 times daily

• Elevation of affected digit

• Avoid squeezing

• Stop nail biting

• Avoid trauma

Chronic

• Keep hands dry

• Avoid prolonged water exposure

• Wear protective gloves (cotton inside, rubber outside)

• Avoid irritants and detergents

• Regular emollient application

• Restore cuticle protection

B. Pharmacological Treatment

1. Acute Paronychia

Early (No Abscess)

Warm soaks + oral antibiotics

Amoxicillin-clavulanic acid 625 mg (PO) every 8 hours for 14 days

Alternative:

• Flucloxacillin

• Cephalexin

With Abscess

Incision and drainage is mandatory

Antibiotics alone will fail if pus present.

2. Chronic Paronychia (Fungal)

Clotrimazole cream 1%Apply every 12 hours for 14 days

AND

Itraconazole 200 mg orally once daily for 14 days

AND (if secondary bacterial infection)

Clindamycin 300 mg orally every 12 hours for 14 days

Adjunct Therapy

• Topical mild corticosteroid (short course)

• Emollients

• Barrier creams

Surgical Management

Indications:

• Fluctuant abscess

• Severe throbbing pain

• Failure of antibiotics

• Nail fold tension

Procedure:Incision along lateral nail fold → drain pus → irrigate → dressing

Complications

• Nail dystrophy

• Permanent nail deformity

• Nail plate separation

• Cellulitis

• Felon

• Osteomyelitis (rare)

• Recurrent infection

Prevention

• Avoid nail biting

• Proper manicure technique

• Avoid cutting cuticles

• Keep hands dry

• Use gloves during wet work

• Control diabetes

• Treat early fungal infections

• Avoid prolonged artificial nails

Prognosis