Indian Journal of DermatologyMedknow Publications

Management of Chronic Paronychia

Vineet Relhan, Khushbu Goel, [...], and Vijay Kumar Garg

Additional article information

Abstract

Chronic paronychia is an inflammatory disorder of the nail folds of a toe or finger

presenting as redness, tenderness, and swelling. It is recalcitrant dermatoses seen

commonly in housewives and housemaids. It is a multifactorial inflammatory reaction

of the proximal nail fold to irritants and allergens. Repeated bouts of inflammation

lead to fibrosis of proximal nail fold with poor generation of cuticle, which in turn

exposes the nail further to irritants and allergens. Thus, general preventive measures

form cornerstone of the therapy. Though previously anti-fungals were the mainstay

of therapy, topical steroid creams have been found to be more effective in the

treatment of chronic paronychia. In recalcitrant cases, surgical treatment may be

resorted to, which includes en bloc excision of the proximal nail fold or an eponychial

marsupialization, with or without nail plate removal. Newer therapies and surgical

modalities are being employed in the management of chronic paronychia. In this

overview, we review recent epidemiological studies, present current thinking on the

pathophysiology leading to chronic paronychia, discuss the challenges chronic

paronychia presents, and recommend a commonsense approach to management.

Keywords: Chronic paronychia, en bloc excision of nail fold, hand dermatitis

Introduction

What was known?

Chronic paronychia was considered a form of fungal infection affecting the nail folds

with anti-fungals being the mainstay of treatment. Surgical management like

eponychial marsupialization and en bloc excision of nail fold was done in recalcitrant

cases without nail plate removal.

Chronic paronychia is an inflammatory recalcitrant disorder affecting the nail folds. It

can be defined as an inflammation lasting for more than 6 weeks and involving one

or more of the three nail folds (one proximal and two lateral).[1] This review aims to

throw a light on the current concepts in etiopathogenesis of chronic paronychia and

brings in detail the past and present management strategies with special focus on

newer therapies.

Structure of nail

The nail is a complex unit composed of five major modified cutaneous structures:

The nail matrix, nail plate, nail bed, cuticle (eponychium), and nail folds.[2] The nail

bed, which consists of 2 portions, is primarily involved in the production, migration,

and maintenance of the nail. The proximal portion, called the germinal matrix,

contains active cells that are responsible for generating new nail. Damage to the

germinal matrix results in malformed nails. The distal portion, the sterile matrix, adds

thickness, bulk, and strength to the nail. The nail arises from a mild proximal

depression called the proximal nail fold. The nail divides the nail fold into 2

components: The dorsal roof and the ventral floor, both of which contain germinal

matrices. Cuticle is an outgrowth of the proximal nail fold (PNF) and is situated

between the skin of the digit and the nail plate, fusing these structures together. This

configuration provides a waterproof seal from external irritants, allergens, and

pathogens. In chronic paronychia, this seal is broken; the irritants enter the space

thus created.

Clinical features

The patient presents with complaint of redness, tenderness, swelling, fluid under the

nail folds, and thick discolored nail [Figure 1]. Morphologically, it is characterized by

induration and rounding off of the paronychium, recurring episodes of acute

eponychial inflammation and drainage. Nail plate may show thickening and

longitudinal grooving. Onychomadesis, transverse striation, pitting, hypertrophy can

be present and are probably due to inflammation of nail matrix.[3] Nail plate may

present a green discoloration of its lateral margins due to Pseudomonas

aeruginosacolonization.

Figure 1A case of paronychia with rounding off of peronychium and thick, discoloured nails

Pathogenesis

Repeated bouts of inflammation, persistent edema, induration, and fibrosis of

proximal and lateral nail folds causes the nail folds to round up and retract, thereby

exposing the nail grooves further. This loss of an effective seal leads to a persistent

retention of moisture, infective organisms and irritants within the grooves, in turn

exacerbating the acute flare-ups. This vicious cycle goes on, compromising the

ability to regenerate the cuticle. The inflamed and fibrosed PNF progressively loses

its vascular supply [Figure 2]. This is responsible for failure of medical treatment

measures. Topical drugs fail to penetrate chronically inflamed skin, and systemic

drugs cannot be delivered to areas of decreased vascular supply.[4]

Figure 2Pathogenesis of chronic paronychia

Etiology

It has a complex pathogenesis and is caused by multifactorial damage to the cuticle,

thereby exposing the nail fold and the nail groove.[5] Previously, it was believed that

chronic paronychia is caused by Candida.[6] However, recent data reveals that it is a

form of hand dermatitis caused by environmental exposure. Candida is often

isolated; however, in many cases, Candida disappears when the physiologic barrier

is restored.[7] Hence, the recent view holds that chronic paronychia is not a mycotic

disease but an eczematous condition with a multifactorial etiology. For this reason,

topical and systemic steroids may be used successfully, whereas systemic anti-

fungals are of little value. Tosti et al.[7] discovered that topical steroids are more

effective than systemic anti-fungals in the treatment of chronic paronychia.

Although Candida was frequently isolated from the PNF of their patients with chronic

paronychia, Candida eradication was not associated with clinical cure in most

patients.

In a study conducted by Rigopoulos D et al.,[8] tacrolimus 1% ointment and

betamethasone 17-valerate cream was found to be more effective in patients of

chronic paronychia than just emollient application, confirming allergens and irritants

have indeed an important contribution to the pathogenesis of chronic paronychia.

Chronic paronychia commonly afflicts house and office cleaners, laundry workers,

food handlers, cooks, dishwashers, bartenders, chefs, nurses, swimmers, diabetes,

and patients on HIV-ART. Hypersensitivity to foodstuff is responsible for an

increased incidence in food handlers.[9]

There are many rare causes of chronic paronychia, which should always be kept in

mind and some of which include the following:

Infections (Bacterial, mycobacterial, or viral)

Raynaud's disease

Metastatic cancer, subungual melanoma, squamous cell carcinoma. Benign

and malignant neoplasms should always be excluded when chronic paronychia does

not respond to conventional treatment

Papulosquamous disorders like psoriasis, vesicobullous disorders-pemphigus

Drug toxicity from medications such as retinoids, epidermal growth factor-

receptor inhibitors (cetuximab), and protease inhibitors. Indinavir- induces retinoid-

like effects and remains the most frequent cause of chronic paronychia in patients

with HIV disease. Retinoids also induce chronic paronychia. The mechanism can be

-nail fragility and minor trauma by small nail fragments.[10] Paronychia has also

been reported in patients taking cetuximab (Erbitux), an anti-epidermal growth factor-

receptor (EGFR) antibody used in the treatment of solid tumors.[11]

Differential diagnosis

The differential diagnosis of chronic paronychia includes squamous cell carcinoma of

the nail, malignant melanoma, metastases from malignant tumors. The clinician

should consider the possibility of the carcinoma when a chronic inflammatory

process is unresponsive to treatment. Any suspicion for the aforementioned entities

should prompt biopsy.

Treatment of chronic paronychia

Various treatment options for management of chronic paronychia have been enlisted

in Table 1.

Table 1Treatment options for management of chronic paronychia

General measures

These measures help in prevention as well as work synergistically with other active

measures in improving the healing time and decreasing further recurrences. The

basic aim is avoidance of aggravating factors and minimizing further injury by

reducing the manipulation of the nail. The former may be achieved by avoiding

exposure to moist environments and contact irritants such as soaps and detergents.

The affected area should be kept dry, and moisturizers should be applied after

washing hands. Rubber gloves should be used, preferably with inner cotton glove or

cotton liners while performing any work with probable exposure to irritants.[12]

Further injury may be minimized by keeping the nails short and avoiding any

manipulation of the nail, such as manicuring, finger sucking, or self attempt to incise

and drain the lesion. The footwear should be properly chosen to avoid unnecessary

damage to the nail. The patients with diabetes should maintain a strict glycemic

control.[12]

Medical management of chronic paronychia

Initially, organisms such as Candida and intestinal bacteria were causally related to

this condition.[13,14] Thus, anti-fungals played an important role in the management

of chronic paronychia in the past, and several studies using topical or systemic anti-

fungals have reported encouraging results. Wong et al.[15] compared the therapeutic

effect of ketoconazole tablets and econazole lotion in the treatment of chronic

paronychia and found them comparable in efficacy. However, they continued to

isolateCandida species in cured patients, thus suggesting that total elimination of

organisms is not necessary for complete recovery. Likewise, bacteria including

micrococci, diphtheroids, and gram-negative organisms were recovered from nail-

folds throughout the treatment period proving the multifactorial origin of the condition.

Daniel et al. assessed the efficacy of ciclopirox 0.77% topical suspension in

combination with a strict irritant-avoidance regimen in patients with simple chronic

paronychia and/or onycholysis and showed excellent therapeutic outcomes.[16]

Though anti-fungals were the mainstay of therapy in the past, some investigators

have suggested that the therapeutic potential of anti-fungals in chronic paronychia

might be attributed equally to the anti-fungal and to the anti-inflammatory properties

of these agents.[1] Even in studies showing a good therapeutic effect, some of the

patients reported unsuccessful anti-fungal therapy in the past.[17] Thus, the

accumulating evidence indicates that chronic paronychia is an eczematous condition

as discussed above.[18,19] For this reason, topical and systemic steroids have

become the first line of therapy, whereas topical and systemic anti-fungals are of

little value now, being used only when there is an associated fungal infection.

Tosti et al.[7] conducted a randomized, double-blind study to compare the efficacy of

systemic anti-fungals (itraconazole 200 mg daily or terbinafine 250 mg daily) versus

a topical corticosteroid (methylprednisolone aceponate cream 0.1%, 5 mg daily) in

the treatment of 45 adult patients with chronic paronychia over 3 weeks. The follow-

up period was of 6 weeks. The statistical analysis showed a significant difference

between the number of nails improved or cured by methylprednisolone aceponate

(41 out of 48) and that of nails improved or cured with terbinafine (30 out of 57) or

itraconazole (29 out of 64). Presence of Candida was not strictly linked to disease

activity, andCandida eradication was associated with clinical cure in only 2 of the 18

patients who carried Candida.

Tacrolimus has been used successfully in treatment of atopic and allergic contact

dermatitis. Based on this fact and that irritants and allergens play a pivotal role of in

the development of chronic paronychia, Rigopoulos et al.[8] conducted a

randomized, unblinded, comparative study to compare the efficacy of tacrolimus

ointment 0.1% vs. betamethasone 17-valerate 0.1% vs. emollient application for 3

weeks in the treatment of 45 patients with chronic paronychia. Both betamethasone

and tacrolimus groups presented statistically significantly greater cure or

improvement rates when compared with the emollient group, and tacrolimus

ointment appeared to be a more efficacious than betamethasone 17-valerate or

placebo for the treatment of chronic paronychia. Possible effect of tacrolimus was

explained by its role in the elicitation phase of allergic contact dermatitis through

inhibition of dendritic cell migration into the draining lymph node[20] and suppression

of both irritant and contact patch test reactions.[21] In addition, the ointment

formulation of the tacrolimus might offer increased benefit on the impaired barrier

function of the inflammatory perionychium.

Surgical management of chronic paronychia

Surgical management is only indicated in recalcitrant cases of chronic paronychia,

which does not respond to medical management and proper use of general

measures. Surgical treatment is required in such cases to remove the chronically

inflamed tissue, which aids in effective penetration of topical as well as oral

medications and regeneration of the cuticle.

Various surgical techniques with modifications have been described in literature.

Keyser et al.[22] in 1975 suggested simple eponychial marsupialization as the

treatment of chronic paronychia. In this technique, after anesthesia and tourniquet

control, a crescent-shaped incision parallel and proximal to the distal edge of

eponychium and extending from the radial to ulnar borders was made [Figure 3]. The

width of the crescent was 3 mm from proximal to distal edge. All affected tissue

within the boundaries of the crescent and extending down to, but not including, the

germinal matrix is excised and packed with gauze pieces. Thus, this procedure

exteriorizes the infected and obstructed nail matrix and allows its drainage.

Epithelialization of the excised defect occurs over the next 2-3 weeks.

Figure 3Eponychial marsupilization in a case of chronic paronychia

Bednar et al.[4] in 1991 treated 7/28 fingers with marsupialization alone and found

recurrences in two of these patients who had nail plate irregularities. The 16 patients

with nail irregularities were treated with marsupialization plus nail removal, and there

were no recurrences with statistically significant difference. The two patients treated

with marsupilization alone who showed recurrence were retreated with

marsupialization and nail removal and both improved significantly. Thus, they further

confirmed that eponychial marsupialization is an effective means of treating chronic

paronychia and suggested that nail removal should also be done when concurrent

nail irregularities are seen as eponychial marsupialization only drains the dorsal

surface of the dorsal roof of germinal matrix, whereas nail removal more thoroughly

debrides the entire nail fold by permitting drainage of the volar portion of the dorsal

roof as well as the ventral floor.

Eponychial marsupilization preserves the ventral surface of the PNF, which forms

the dorsal roof or surface of the nail plate, thus the authors claimed that it produces a

cosmetically more acceptable result as compared to en bloc excision of PNF

(complete removal of the dorsal roof including the eponychium), since it prevents any

subsequent roughness or lack of shininess over the nail plate surface.

Baran et al.[23] Suggested en bloc excision of proximal nail fold as a treatment

option for chronic paronychia based on their observation that sites of biopsies from

proximal nail fold in cases of collagen disorders healed uneventfully without scarring

or distortion in about three weeks. In this procedure, they excised a crescent-shaped

piece of full thickness skin, 5-6 mm wide at greatest diameter that extends from one

lateral nail fold to the opposite one and includes the entire proximal nail fold [Figure

4]. Complete healing and restoration occurred in three months. They postulated that

this method was simpler, curative, and cosmetically and functionally more

satisfactory than eponychial marsupialization.

Figure 4En bloc excision of the proximal nail fold in a case of chronic pronychia

Grover et al.[24] treated 30 patients of chronic paronychia with nail plate irregularities

by en bloc excision of PNF with or without nail plate removal. Of these, 70% of

patients were cured in group, in which en bloc excision with nail avulsion was

performed, whereas only 41% were cured in group where en bloc excision without

nail avulsion was performed; however, the difference was not significant statistically.

Thus, they concluded that though en bloc excision of the PNF is a useful method in

recalcitrant paronychia, simultaneous nail avulsion improves the surgical outcome.

The authors also claimed that a fibrosed, avascular distal eponychium would not

contribute effectively towards a normal nail plate surface or produce a new cuticle as

postulated by supporters of eponychial marsupilization, and thus preserving the

eponychium does not offer any added advantage. Moreover, all these patients of en

bloc excision of PNF showed an effective regeneration of eponychium and cuticle

with normal attachment to nail plate and no loss of post-op shininess.

Recently, Pabari et al.[25] described Swiss roll technique for chronic and severe

acute paronychia with run around infection involving both nail folds. In this technique,

the nail fold is elevated by making an incision on either side using a no. 15 scalpel

blade with the scalpel tip pointed away from the nail bed to prevent iatrogenic

deformity of the nail [Figure 5]. The elevated nail fold is reflected proximally over a

non-adherent dressing [Figure 6] that is rolled up like a Swiss roll and secured to the

skin with 2 anchoring non-absorbable sutures. The exposure of the nail bed allows

drainage of any residual infection. The finger is subsequently dressed with a simple

finger dressing. If the wound is clean at 48 hours, the anchoring sutures are

removed, and the nail fold is allowed to fall back to its original position and heal by

secondary intention. In chronic paronychia, the fold may be kept open for up to 7

days to allow adequate drainage. This technique has the advantage of retaining the

nail plate and allowing rapid healing without creating a defect in the skin.

Figure 5Swiss roll technique: Incision made on either side of nail fold for nail fold elevation (adapted from Pabari A, Iyer S, Khoo CT. Swiss roll technique for treatment of paronychia. Tech Hand Surg 2011;15:75-7)

Figure 6Swiss roll technique: Elevated nail fold is reflected proximally over a non-adherent dressing (adapted from Pabari A, Iyer S, Khoo CT. Swiss roll technique for treatment of paronychia. Tech Hand Surg 2011;15:75-7)

Prognosis

Chronic paronychia responds slowly to treatment and may take several weeks or

months, but this should not be a deterrent to therapy. If the patient is not treated,

sporadic painful episodes of acute inflammation may be experienced as a result of

continuous penetration of various pathogens.

Conclusion

Thus, chronic paronychia should no longer be considered a mycotic disease but an

eczematous condition with multifactorial etiology. Preventive measures should

always form the main part of therapy. Topical steroids have a major role to play in

therapy and are more effective than systemic anti-fungals (level of evidence B).

Tacrolimus has recently shown to have promising results. Surgical therapy should be

resorted to in recalcitrant cases, and simultaneous nail removal augments the results

in most cases.

What is new?

Chronic paronychia has a multifactorial etiology and is primarily a form of hand

dermatitis and not fungal infection. Steroids have a definite edge over anti-fungals in

the management of chronic paronychia. Tacrolimus has recently shown to have

promising results. The surgical methods used for recalcitrant cases give better

results when the nail plate is also removed simultaneously. A new surgical technique

namely Swiss roll technique has been described, which has the advantage of

retaining the nail plate and allowing rapid healing without creating a defect in the

skin.

Article informationIndian J Dermatol. 2014 Jan-Feb; 59(1): 15–20.doi: 10.4103/0019-5154.123482

PMCID: PMC3884921

Vineet Relhan, Khushbu Goel, Shikha Bansal,1 and Vijay Kumar Garg2

From the Department of Dermatology, VMMC and Safdurjung Hospital, Delhi, India1Specialist, VMMC and Safdurjung Hospital, Delhi, India2Director Professor and Head, MAMC, VMMC and Safdurjung Hospital, Delhi, IndiaAddress for correspondence: Dr. Vineet Relhan, 35-F, Sector-7, SFS Flats, Jasola Vihar, New Delhi - 25, India. E-mail: vineetrelhan/at/gmail.com

Received December 2012; Accepted February 2013.

Copyright : © Indian Journal of DermatologyThis is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Articles from Indian Journal of Dermatology are provided here courtesy of Medknow Publications

References1. Rockwell GP. Acute and chronic paronychia. Am Fam Physician. 2001;63:1113–6.[PubMed]

2. Fleckman P. Structure and function of the nail unit. In: Scher RK, Daniel CR III, editors. Nails: Diagnosis, Therapy, Surgery. Oxford, UK: Elsevier Saunders; 2005. p. 14.

3. Grover C, Reddy BSN, Chaturvedi KU. Nail biopsy, an assessment of indications and outcome. Dermatol Surg. 2005;31:190–4. [PubMed]

4. Bednar MS, Lane LB. Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia. J Hand Surg Am. 1991;16:314–7. [PubMed]

5. Habif TP. Clinical Dermatology: A color guide to diagnosis and therapy. 4th ed. Edinburgh, UK: Mosby; 2004. Nail diseases; pp. 871–2.

6. Hay RJ, Baran R, Morre MK, Wilkinson JD. Candida onychomycosis – an evaluation of the role of Candida species in nail disease. Br J Dermatol. 1988;118:47–58. [PubMed]

7. Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungal in the treatment of chronic paronychia: An open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002;47:73–6. [PubMed]

8. Rigopoulos D, Gregoriou S, Belyayeva E, Larios G, Kontochristopoulos G, Katsambas A. Efficacy and safety of tacrolimus ointment 0.1% vs. betamethasone 17-valerate 0.1% in the treatment of chronic paronychia: An unblinded randomized study. Br J Dermatol.2009;160:858–60. [PubMed]

9. Tosti A, Guerra L, Morelli R, Bardazzi F, Fanti PA. Role of foods in the pathogenesis of chronic paronychia. J Am Acad Dermatol. 1992;27:706–9. [PubMed]

10. Tosti A, Pirracini B, Antuono AD. Paronychia associated with antiretroviral therapy. Br J Dermatol. 1999;140:1165–8. [PubMed]

11. Roe E, Garcia MP, Marcuello E. Description and management of cutaneous side effects during cetuximab or erlotinib treatments: A prospective study of 30 patients. J Am Acad Dermatol. 2006;55:429–37. [PubMed]

12. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008;77:339–48. [PubMed]

13. Samman PD. Textbook of Dermatology. 3rd ed. Vol. 2. Oxford: Blackwell Scientific Publications; 1979. pp. 1834–5.

14. Barlow AJ, Chattaway FW, Holgate MC, Aldersley T. Chronic paronychia. Br J Dermatol. 1970;82:448–53. [PubMed]

15. Wong ES, Hay RJ, Clayton YM, Noble WC. Comparison of the therapeutic effect of ketoconazole tablets and econazole lotion in the treatment of chronic paronychia. Clin Exp Dermatol. 1984;9:489–96. [PubMed]

16. Daniel CR, Daniel MP, Daniel J, Sullivan S, Bell FE. Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen.Cutis. 2004;73:81–5. [PubMed]

17. Amichai B, Shiri J. Fluconazole 50 mg⁄day therapy in the management of chronic paronychia. J Dermatolog Treat. 1999;10:199–200.

18. Tosti A, Piraccini BM. Paronychia. In: Amin S, Lahti A, Maibach HI, editors. Contact urticaria syndrome. Boca Raton (FL): CRC Press; 1997. pp. 267–78.

19. Zaias N. Paronychia. In: Zaias N, editor. The nail in health and disease. 2nd ed. Norwalk (CT): Appleton and Lange; 1990. pp. 131–5.

20. Baumer W, Sülzle B, Weigt H. Cilomilast, tacrolimus and rapamycin modulate dendritic cell function in the elicitation phase of allergic contact dermatitis. Br J Dermatol.2005;153:136–44. [PubMed]

21. Lauerma AI, Stein BD, Homey B. Topical FK 506: Suppression of allergic and irritant contact dermatitis in the guinea pig. Arch Dermatol Res. 1994;286:337–40. [PubMed]

22. Keyser JJ, Eaton RG. Surgical cure of chronic paronychia by eponychial marsupialization. Plast Reconstr Surg. 1976;58:66–70. [PubMed]

23. Baran R, Bureau H. Surgical treatment of recalcitrant chronic paronychia of the fingers. J Dermatol Surg Oncol. 1981;7:106–7. [PubMed]

24. Grover C, Bansal S, Nanda S. En bloc excision of proximal nail fold for treatment of chronic paronychia. Dermatol Surg. 2006;32:393–8. [PubMed]

25. Pabari A, Iyer S, Khoo CT. Swiss roll technique for treatment of paronychia. Tech Hand Surg. 2011;15:75–7. [PubMed]