management of chronic paronychia
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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]