PYOGENIC PARONYCHIA

Paronychia is an inflammatory reaction involving the folds of the skin

surrounding the fingernail. It is characterized by acute or chronic purulent, tender,
and painful swellings of the tissues around the nail, caused by an abscess in the
nailfold. When the infection becomes chronic, horizontal ridges appear at the base
of the nail. With recurrent bouts new ridges appear.
The primary predisposing factor that is identifiable is separation of the
eponychium from the nail plate. The separation is usually caused by trauma as a
result of moistureinduced maceration of the nailfolds from frequent wetting of the
hands. The relationship is close enough to justify treating chronic paronychia as
workrelated in bartenders, food servers, nurses, and others who often wet their
hands. The moist grooves of the nail and nailfold become secondarily invaded by
pyogenic cocci and yeasts. The causative bacteria are usually S. aureus,
Streptococcus pyogenes, Pseudomonasspecies, Proteusspecies, or anaerobes. The
pathogenic yeast is most frequently Candida albicans.
The bacteria usually cause acute abscess formation (Staphylococcus) (Fig.
146) or erythema and swelling (Streptococcus) (Fig. 147), and C. albicans most
frequently causes a chronic swelling. If an abscess is suspected, applying light
pressure with the index finger against the distal volar aspect of the affected digit
will better demonstrate the extent of the collected pus by inducing a welldemarcated blanching. Smears of purulent material will help confirm the clinical
impression. Myremecial warts may at times mimic paronychia. Subungual black
macules followed by edema, pain, and swelling have been reported to be a sign of
osteomyelitis caused by S. aureusor Streptococcus viridans, in children with
atopic dermatitis.
Treatment of pyogenic paronychia consists mostly of protection against
trauma and concentrated efforts to keep the affected fingernails meticulously dry.
Rubber or plastic gloves over cotton gloves should be used whenever the hand
must be placed in water. Acutely inflamed pyogenic abscesses should be incised
and drained. The abscess may often be opened by pushing the nailfold away from
the nail plate. In acute suppurative paronychia, especially if stains show pyogenic
cocci, a semisynthetic penicillin or a cephalosporin with excellent staphylococcal
activity should be given orally. If these are ineffective, MRSA or a mixed

anaerobic bacteria infection should be suspected. Augmentin for the latter or

treatment dictated by the sensitivities of the cultured organism will improve cure
rates. Rarely, longterm antibiotic therapy may be required.
While Candidais the most frequently recovered organism in chronic
paronychia, topical or oral antifungals lead to cure in only about 50% of cases. If
topical steroids are used to decrease inflammation and allow for tissue repair,
cure results more reliably (nearly 80% in one study). Often an antifungal liquid
such as miconazole is combined with a topical corticosteroid cream or ointment.
CANDIDAL PARONYCHIA
Inflammation of the nailfold produces redness, edema, and tenderness of
the proximal nailfolds, and gradual thickening and brownish discoloration of the
nail plates. Usually the fingernails only are affected. Patients commonly have an
atopic background.
While acute paronychia is usually staphylococcal in origin, chronic
paronychia is commonly multifactorial in origin. Irritant dermatitis and
candidiasis may play important roles. In one study, treatment with a topical
corticosteroid was superior to treatment with an anticandidal agent. Avoidance of
irritants and wet work is essential. Anticandidal agents may be of use in this
setting, and may be used in combination with a topical corticosteroid.
Candidal paronychia is frequently seen in patients with diabetes, and one
aspect of the treatment consists of bringing the diabetes under control. The
avoidance of chronic exposure to moisture and irritants is also essential in these
patients. If topical treatment fails, oral fluconazole once a week or itraconazole in
pulsed dosing can be effective.
Repetitive contact urticaria or allergic contact dermatitis to foods and
spices may mimic candidal paronychia. Patch and radioallergosorbent testing
(RAST) may be of value.

The affected digit becomes swollen, red and painful (Fig. 71.17). Compression of
the nail fold may produce purulent drainage. Acute paronychia is most commonly
due to bacteria, in particular Staphylococcus aureusor Streptococcus pyogenes,
and it follows minor trauma to the nail. Recurrent episodes of acute paronychia
should raise the suspicion of an HSV infection. Viral cultures, direct fluorescent
antibody assay, and/or PCR should be obtained to identify the responsible agent.
Treatment:
-

Drainage of the abscess.

Systemic antibiotics according to culture results.
Systemic antivirals when due to HSV.

Chronic paronychia commonly involves the fingernails of adult women. Although

the pathogenesis is still debated, there is accumulating evidence that the condition
represents a contact reaction to irritants or allergens. Occupational chronic
paronychia is common in food handlers. Chronic paronychi is clinically
characterized by inflammation of the proximal nail fold with erythema, edema and
absence of the cuticle. One or several fingernails (especially the thumb and second
or third fingers of the dominant hand) are affected. Damage to the nail matrix
results in nail plate surface abnormalities such as Beaus lines.
Chronic paronychia usually assumes a prolonged course with superimposed,
recurrent, selflimited episodes of acute exacerbation. Secondary infections with
Candidaspp. and Pseudomonas aeruginosaare common.
Treatment
-

Avoidance of water and chemical exposure.

Topical corticosteroids.
Topical imidazoles.
Topical antiseptics (e.g. 4% thymol in 95% ethanol).
Systemic antifungals are not useful