Professional Documents
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Review
Toenail paronychia
Adam Lomax *, James Thornton, Dishan Singh
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom
A R T I C L E I N F O A B S T R A C T
Article history: Paronychia is an inflammation of the tissues alongside the nail. It may be acute or chronic and can be
Received 25 February 2015 seen in isolation or in association with an ingrowing toenail. Acute paronychial infections develop when
Accepted 10 September 2015 a disruption occurs between the seal of the nail fold and the nail plate, providing a portal of entry for
invading organisms.
Keywords: The treatment of paronychia associated with an ingrowing toenail is aimed at treating the causal
Paronychia toenail. In paronychia not associated with an ingrowing toenail, antibiotics may cure an early infection
Ingrowing toenail
but surgical drainage of an abscess is often required. In this case, an intra-sulcal approach is preferable to
Onychocryptosis
a nail fold incision.
Chronic paronychia is less common in the feet than in the hands. It is a form of contact dermatitis and
is frequently non-infective, however the chronically irritated tissue may become secondarily colonised
by fungi. A dermatology consultation should be obtained for suspected chronic paronychia. Patients with
chronic paronychia that is unresponsive to standard treatment should be investigated for unusual
causes, such as malignancy.
An algorithm for the treatment of paronychia is presented in this review.
Crown Copyright ß 2015 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2. Anatomy of the nail complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3. Acute paronychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.1. Acute paronychia in association with an ingrowing toe nail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.1.1. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.2. Acute paronychia not associated with ingrown toenail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.2.1. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4. Chronic paronychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
5. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
1. Introduction entry of organisms into the sulcus between the nail and nail fold
leads to bacterial or fungal infection of that area. Paronychia may
Paronychia is defined as an inflammation of the folds of tissue be acute or chronic, and the aetiology and treatment are different
(proximal or lateral) surrounding the nail of a toe or finger (Fig. 1) for each. The two forms should be considered as completely
[1]. Infective paronychia usually results from a breakdown of the separate entities.
protective barrier between the nail and the nail fold. Subsequent Much of the literature reviewed here concerns paronychia of
the finger, reflecting the paucity of literature relating to paronychia
in the toe. The presentation and treatment in the upper and lower
* Corresponding author. Tel.: +44 20 8954 2300. extremity does have many similarities. This literature is therefore,
E-mail address: 1adamlomax@gmail.com (A. Lomax). undoubtedly relevant and transferable in general terms. However,
http://dx.doi.org/10.1016/j.fas.2015.09.003
1268-7731/Crown Copyright ß 2015 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
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FAS-862; No. of Pages 5
Fig. 1. Nomenclature of the nail and nail folds. The sulcus between the nail plate and
the nail fold is invaded by organisms when the protective seal between them is
broken, resulting in an acute paronychial infection.
In acute paronychia there is a rapid onset (over 2–5 days) of (Fig. 5a) and the nail becomes ballotable. This pressure can cause
discomfort, redness, swelling and tenderness of one of the nail permanent damage to the germinal matrix (Fig. 5b).
folds (Fig. 3a) due to a breakdown of the nail plate/nail fold barrier. An untreated abscess in one nail fold may also track around to
Acute paronychia of the toes is often due to ingrown nails. This is involve all of the nail folds resulting in the so-called ‘‘run-around’’
not usually true of paronychia of the fingers, where a history of infection (Fig. 6). In more advanced cases, pus may theoretically
minor nail trauma is more common. The initial inflammation may track into other tissues of the digit. We have not however, found
progress to a frank bacterial infection with subsequent accumula- any documented case of acute paronychia leading to digit pulp
tion of pus (Fig. 3b). An untreated infection may also eventually abscesses, tenosynovitis or osteomyelitis in the literature.
lead to the formation of granulation tissue around the nail fold
(Fig. 3c). The most common causative infective organism is 3.1. Acute paronychia in association with an ingrowing toe nail
Staphylococcus aureus, but Streptococcus, Pseudomonas species,
gram-negative bacteria and Candida albicans have all also been The term ingrowing toenail is a misnomer, since the nail plate
isolated [2–4]. Anaerobes are more frequent in patients with does not ‘‘grow’’ into the lateral nail folds. However, the term
exposure of the nail to oral flora [2]. ingrowing toenail remains in regular use both in common and
The initial abscess formation in between the nail plate and nail medical language. Associated factors include improperly trimmed
fold (Fig. 4a) may track around the nail plate (Fig. 4b), becoming a nails, poorly fitted shoes, tight socks, excessive sweating, soft
subungual abscess. This separates and elevates the nail plate from tissue abnormalities of the toe and inherent nail deformity [5]. It
its bed (germinal matrix in the proximal nail fold or sterile matrix can occur both in normal and abnormal (wide or incurvated)
in the lateral). If the abscess tracks beneath the proximal nail plate, toenail morphology. A common scenario is the use of fingernail
it can generate enough pressure to elevate the nail plate from the clippers to cut a relatively wide or incurvated toenail in a rounded
germinal matrix. Pus will then be visible underneath the nail plate fashion. There is subsequent avulsion of the toenail edge, causing
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
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FAS-862; No. of Pages 5
Fig. 3. Initial inflammation of the lateral nail fold (a) may proceed to pus formation (b) and then to excessive granulation tissue formation (c).
traumatic separation of the nail plate from the nail fold and cause nail deformity and present as a paronychia associated with
occasionally leaving an edge of nail (fish hook; Fig. 3a) that an ingrowing toenail (Fig. 7).
continues to act as a foreign body irritant. This causes localised
trauma and a portal of entry for infective organisms and may lead 3.1.1. Treatment
to bacterial infection (Fig. 3b). In addition a vascular, red and In cases where an ingrown toenail is present, this must be
tender hyper-granulation tissue can arise from the nail sulcus addressed if successful cure is to be achieved. Initial treatment for
(Fig. 3c). It should also be noted that a subungual exostosis might an ingrowing nail due to a nail spike is to skilfully remove the
offending spike, often with very little discomfort. If this is too
painful, then a local anaesthetic digital nerve block can be used.
The application of an antiseptic dressing and prescription of oral
antibiotics may be necessary, particularly in diabetics and people
with poor peripheral circulation. Once the nail spike is removed,
the nail fold usually heals well [6].
If the paronychia due to an ingrowing nail is severe, recurrent or
associated with a toenail abnormality, treatment with simple
partial or complete nail avulsion without ablation has a high
recurrence rate [6,7]. In this scenario, a nail wedge avulsion and
ablation is relatively simple and very successful for long-term
relief. A number of surgical ablative procedures are performed.
Fig. 4. The nail and its surrounding structures shown in cross section. The initial
abscess in the sulcus between the nail and nail fold (a) may extend around the
nail plate into the subungual region to separate and elevate the nail plate from its
matrix (b).
Fig. 5. A proximal nail fold paronychia has tracked under the nail plate to separate it
from its matrix (a), making the nail ballotable. (b) shows the indentation caused in
the nail matrix after removal of the nail, resulting from the pressure of the Fig. 6. An abscess in one isolated nail fold may track around to involve the other nail
accumulated pus. folds, causing a run-around infection.
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
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FAS-862; No. of Pages 5
3.2.1. Treatment
Management of acute paronychia not associated with an
ingrown toenail is largely dependent on the amount of inflamma-
tion and whether an abscess is present. In patients who present
with a minimal amount of inflammation and no abscess formation,
warm water or antiseptic soaks 3–4 times per day until symptoms
resolve is often successful [11–15]. Addition of oral antibiotics with
gram-positive coverage against Staphylococcus aureus may be
prescribed [12,16,17]. No study has been performed to evaluate the
Fig. 7. A podiatrist had planned to perform a nail wedge resection for an ingrowing
effectiveness of soaks alone without the addition of oral
toenail, but had to abandon the procedure when it was realised that the cause was a antimicrobials [18]. Coverage for anaerobes should be considered
subungal exostosis causing nail deformity. if oral flora is suspected. In cases of known or suspected
methicillin-resistant Staphylococcus aureus, appropriate alterna-
Incisional techniques (Zadik, Winograd etc.) used for the treatment tive therapy must be given [12,16,17].
of ingrowing toenail are not recommended in the presence of If the paronychia does not resolve within 48 h or if it progresses
infection [8,9]. As it is necessary to treat both the paronychia and to an abscess, it should be drained [19]. In most cases, the pus may
ingrowing toenail in combination, non-incisional techniques such be drained even without local anaesthesia using an intra-sulcal
as electro cauterisation, laser surgery, or chemical agents such as technique. Drainage is achieved by introducing a blunt instrument
phenol or sodium hydroxide are preferable and can be performed (e.g. haemostat/artery clamp or small elevator) into the sulcus
safely even in the presence of infection. Simple partial or complete between the lateral nail fold and the nail plate (Fig. 9) [20,21]. This
nail avulsion with phenol ablation (Fig. 8) has been recommended is directed towards the site of maximal swelling and the nail fold is
as the treatment of choice by a recent Cochrane review of surgical elevated away from the nail until pus is released. No incision is
treatments [10]. The rate of recurrence is less than 5% and the necessary, and upon release of the pus the cavity can be opened
procedure can be repeated successfully in cases of recurrence. with a gentle spread of an artery clamp. A fine strip of mesh gauze
may be placed into the fold to ensure continued drainage for 48 h,
3.2. Acute paronychia not associated with ingrown toenail followed by warm saline soaks until the erythema settles. When
Fig. 8. Nail edge avulsion followed by phenol ablation. Fig. 9. Intra-sulcal drainage of an acute paronychia.
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
G Model
FAS-862; No. of Pages 5
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003