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Emergency Medicine > INFECTIOUS DISEASES
Paronychia
Article Last Updated: Dec 6, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Heather Murphy-Lavoie, MD, FAAEM, Clinical Instructor, Section of Emergency Medicine and Hyperbaric Medicine, Charity Hospital, Louisiana State University
Heather Murphy-Lavoie is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Coauthor(s):
Micelle J Haydel, MD, Assistant Clinical Professor of Medicine, Assistant Program Director, Department of Emergency Medicine, Louisiana State University
Editors: Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jeter (Jay) Pritchard Taylor III, MD, Compliance Officer, Attending Physician Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
run-around, paronychial infection, onychia lateralis, onychia periungualis, inflammation of the nail fold, incision and drainage, I and D, I&D, paronychia, nail infection, superficial infection of the epithelium, staphylococci, infection of the hand, paronychia, finger infection
Background
A paronychia is a superficial infection of epithelium lateral to the nail plate. The acute painful purulent infection is most frequently caused by staphylococci. The patient's condition and discomfort are markedly improved by a simple drainage procedure.
Pathophysiology
A paronychial infection usually starts in the lateral nail fold. Occasionally, the infection includes the complete margin of skin around the nail plate. It results from mechanical separation of the nail plate from the perionychium. Early in the course of this disease process (<24 h), cellulitis alone may be present. An abscess can form if the infection does not resolve quickly.
Frequency
United States
Paronychia is the most common infection of the hand.
Mortality/Morbidity
Failure to properly treat a paronychia can result in hand infection and, occasionally, systemic infection from hematogenous extension.
- The abscess initially forms on the lateral nail fold. It can spread to the eponychium, eventually forming a "horseshoe" that includes the opposite nail fold.
- It may spread to the pulp space of the finger, creating a felon.
- An untreated infection can spread to the deep spaces of the hand and beyond.
Sex
Paronychia is more common in females than in males, with a female-to-male ratio of 3:1.
Age
No predilection exists.
History
The patient is otherwise healthy but complains of acute onset of pain and swelling around the nail.
- Patients may give a history of nail biting, finger sucking, trivial finger trauma, finger exposure to chemical irritants, acrylic nails or nail glue, sculpted nails, or frequent hand immersion in water.
- Query patients about the duration of symptoms, history of nail infections and previous treatment, and exposure to chemicals or water.
- It is important to identify patients with diabetes mellitus, immunocompromise, or history of steroids and retroviral use. Indinavir and lamivudine, in particular, are thought to be associated with an increased incidence of paronychia formation. Painless swelling or severe swelling that radiates requires an expanded differential diagnosis.
- Pain and swelling surrounding the nail are the most common complaints.
Physical
- Erythema
- Edema
- Tenderness along the lateral nail fold
- Fluctuance
- Any tissue irregularity that may be a clue to malignancy
- Vesicles that are consistent with herpetic infection
- Green coloration of the nail may suggest Pseudomonas species infection
Causes
- Paronychia is most commonly caused by Staphylococcus aureus or Streptococcus species.
- A mixed bacterial infection is not uncommon, particularly in patients with diabetes.
- If recurrent or chronic, the infection has an increased likelihood of being mycotic.
Felon
Fingertip Injuries
Hand Infections
Herpetic Whitlow
Psoriasis
Other Problems to be Considered
Bowen disease
Kaposi sarcoma
Malignant melanoma
Onychomycosis
Pemphigus vulgaris
Pyogenic granuloma
Reiter disease
Splinters, foreign body
Mucous cyst
Subungual fibroma
Glomus tumor
Blastomycosis
Squamous cell carcinoma
Lab Studies
- A gram stain and wound culture may be performed, although they are not routinely necessary.
- Obtain a slide preparation using potassium hydroxide (KOH) and fungal culture if candida infection is suspected.
Imaging Studies
- Obtain a plain film x-ray of the fingertip if osteomyelitis is suspected because of recurrent infection, elevated erythrocyte sedimentation rate (ESR), or presence of risk factors for osteomyelitis.
- Consider an x-ray if the patient has a history of recent finger trauma.
- Obtain an x-ray to rule out foreign body.
Prehospital Care
The patient with a paronychia is typically ambulatory. Splinting the finger with clean gauze is necessary to decrease discomfort until definitive treatment is rendered.
Emergency Department Care
- The treatment of choice for a paronychia is incision and drainage.
- Provide warm compresses or soaks with half-strength hydrogen peroxide.
- Elevate the infected nail.
- Keep fingers clean and dry.
- Incision and drainage
- Incision and drainage are not indicated for herpetic whitlow (the most common infection mistaken for paronychia), mucous cyst, glomus tumor, and osteomyelitis.
- For maximum patient comfort, the digit is anesthetized with an appropriate digital nerve block.
- The nail plate and surrounding skin are cleaned with an appropriate antiseptic agent. Blunt dissection with the tip of a sharp instrument or point of a surgical blade is used to elevate the lateral nail fold. The operator attempts to enter the sulcus between the lateral nail plate and lateral epithelium. Purulent drainage can erupt when the sulcus is entered by the instrument tip. The lateral fold of skin should be elevated slightly and irrigated with isotonic sodium chloride solution using a catheter tip syringe.
- A "run-around" describes a severe paronychia that extends along the medial and lateral nail edges. In such cases, or when a large paronychia is present, the cavity should be splinted open with a small wick to prevent adhesion and reformation.
- If purulence has tracked under the nail, excision of the ipsilateral nail may be necessary.
- The presence of a subungual abscess (ie, "floating nail") requires nail plate removal. The degree of debridement is commensurate with the degree of nail bed infection.
Consultations
It is necessary to consult a hand surgeon if cellulitis, deep space infection, glomus tumor, mucous cyst, or osteomyelitis is suspected.
Antibiotics are not necessary if the incision successfully achieves adequate drainage. If cellulitis is present, antibiotics are indicated. In consideration of allergies and contraindications, a third-generation oral cephalosporin agent is the first-line therapy for outpatient treatment. Combination therapy with an IV agent that provides antimicrobial activity against staphylococcus is used for inpatient therapy. See Hand Infections for a detailed discussion of antibiotics.
Drug Category: Antibiotic
Therapy must cover all likely pathogens in the context of the clinical setting.
| Drug Name | Cephalexin (Keflex) |
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| Description | First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora. Used for skin infections or prophylaxis in minor procedures. |
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| Adult Dose | 500 mg PO qid for 7-10 d |
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| Pediatric Dose | 25-50 mg/kg PO divided qid; not to exceed 4 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with aminoglycosides increases nephrotoxic potential |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal impairment |
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Further Inpatient Care
- Admission for paronychia is rarely required unless associated with a significant cellulitis or deep space infection requiring IV antibiotics.
Further Outpatient Care
- Instruct patients to leave any wick in place for 24-48 hours, depending on the depth and extent of the purulent space.
- After removing the wick, patients can begin warm soaks tid/qid and should return to the hospital in 48 h after incision and drainage for examination.
Deterrence/Prevention
- Trim hangnails to a semilunar smooth edge with a clean sharp nail plate trimmer. Trim toenails flush with the toe tip. Do not bite the nail plate.
- Avoid prolonged hand exposure to moisture. If hand washing must be frequent, use antibacterial soap, thoroughly dry hands with a clean towel, and apply an antibacterial moisturizer.
- Wear rubber or latex-free gloves.
- Control diabetes mellitus.
Complications
- Paronychial infections may spread to the pulp space of the finger, developing a felon.
- If neglected, infection may continue to spread to involve the deep spaces of the hand.
- Secondary ridging, thickening, and discoloration of the nail may be observed.
- Nail loss may occur.
Prognosis
- The prognosis is usually good if treated promptly.
- The incidence of chronic paronychia is increased among individuals who have had a prior episode.
Patient Education
Medical/Legal Pitfalls
- Failure to incise and drain adequately
- Failure to have patient return for rechecks until infection is clearly resolving
- Failure to place a wick to hold open abscess cavity during first 24 h
- Failure to remove lateral nail if a subungual infection is present
- Unnecessary treatment with antibiotics
Special Concerns
- Paronychia has been known to initiate from malignant lesions. Any history of prior malignancy or a pigmented irregular appearance of surrounding tissue should result in appropriate suspicion and referral for biopsy.
- Painless swelling lateral to the nail plate in a patient with osteoarthritis should prompt investigation for mucous cyst.
- Constant severe pain with nail plate elevation, bluish-discoloration of the nail plate, and blurring of the lunula suggest the presence of a glomus tumor.
- Brook I. Aerobic and anaerobic microbiology of paronychia. Ann Emerg Med. Sep 1990;19(9):994-6. [Medline].
- Canales FL, Newmeyer WL III, Kilgore ES Jr. The treatment of felons and paronychias. Hand Clin. Nov 1989;5(4):515-23. [Medline].
- Colson AE, Sax PE, Keller MJ, et al. Paronychia in association with indinavir treatment. Clin Infect Dis. Jan 2001;32(1):140-3. [Medline].
- Dahdah MJ, Scher RK. Nail diseases related to nail cosmetics. Dermatol Clin. Apr 2006;24(2):233-9. [Medline].
- Daniel CR, Daniel MP, Daniel J, et al. Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen. Cutis. Jan 2004;73(1):81-5. [Medline].
- Daniel CR III. Paronychia. Dermatol Clin. Jul 1985;3(3):461-4. [Medline].
- Engineer L, Norton LA, Ahmed AR. Nail involvement in pemphigus vulgaris. J Am Acad Dermatol. Sep 2000;43(3):529-35. [Medline].
- Jebson PJ. Infections of the fingertip. Paronychias and felons. Hand Clin. Nov 1998;14(4):547-55, viii. [Medline].
- Jules KT, Bonar PL. Nail infections. Clin Podiatr Med Surg. Apr 1989;6(2):403-16. [Medline].
- Kapellen TM, Galler A, Kiess W. Higher frequency of paronychia (nail bed infections) in pediatric and adolescent patients with type 1 diabetes mellitus than in non-diabetic peers. J Pediatr Endocrinol Metab. Jun 2003;16(5):751-8. [Medline].
- Muniz AE, Evans T. Chronic paronychia, osteomyelitis, and paravertebral abscess in a child with blastomycosis. J Emerg Med. Oct 2000;19(3):245-8. [Medline].
- Perkins MN, Whithead SA. Electrophysiology of medial forebrain bundle connexions with preoptic anterior hypothalamic neurones [proceedings]. J Physiol. Feb 1978;275:16P. [Medline].
- Riesbeck K. Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological diagnosis is crucial. J Clin Microbiol. Oct 2003;41(10):4901-3. [Medline].
- Tosti A, Piraccini BM, D''Antuono A, et al. Paronychia associated with antiretroviral therapy [In Process Citation]. Br J Dermatol. Jun 1999;140(6):1165-8. [Medline].
- Turkmen A, Warner RM, Page RE. Digital pressure test for paronychia. Br J Plast Surg. Jan 2004;57(1):93-4. [Medline].
- Yip KM, Lam SL, Shee BW, et al. Subungual squamous cell carcinoma: report of 2 cases. J Formos Med Assoc. Aug 2000;99(8):646-9. [Medline].
Paronychia excerpt Article Last Updated: Dec 6, 2006
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