Review Article

Acute and Chronic Paronychia of

the Hand

Abstract
Adam B. Shafritz, MD Acute and chronic infections and inflammation adjacent to the
Jeff M. Coppage, MD fingernail, or paronychia, are common. Paronychia typically develops
following a breakdown in the barrier between the nail plate and the
adjacent nail fold and is often caused by bacterial or fungal pathogens;
however, noninfectious etiologies, such as chemical irritants,
excessive moisture, systemic conditions, and medications, can cause
nail changes. Abscesses associated with acute infections may
spontaneously decompress or may require drainage and local wound
care along with a short course of appropriate antibiotics. Chronic
infections have a multifactorial etiology and can lead to nail changes,
including thickening, ridging, and discoloration. Large, prospective
studies are needed to identify the best treatment regimen for acute and
chronic paronychia.

I nflammation of the tissue immedi-

From the Department of Orthopaedics
and Rehabilitation, University of
Vermont College of Medicine,
Burlington, VT.
Neither of the following authors nor
any immediate family member has
received anything of value from or has
stock or stock options held in
a commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Shafritz and
Dr. Coppage.
J Am Acad Orthop Surg 2014;22:
165-174
http://dx.doi.org/10.5435/
JAAOS-22-03-165
Copyright 2014 by the American
Academy of Orthopaedic Surgeons.
ately surrounding the nail, known
as paronychia, is commonly caused by
acute or chronic infection. Paronychia
can be acute (,6 weeks duration) or
chronic ($6 weeks duration) and
typically develops following a break-
down in the barrier between the nail
plate and the adjacent nail fold that is
often caused by bacterial or fungal
pathogens. However, noninfectious
etiologies such as chemical irritants,
excessive moisture, systemic con-
ditions, and medications also can
cause paronychia. Management op-
tions include activity modification
along with medical and/or surgical
intervention based on the etiology,
duration, extent of paronychial
involvement, and the associated risk
factors present.1,2
Anatomy
The tip of the finger is composed of
osseous tissue, soft tissue, and spe-
cialized tissues that produce and sup-
port the nail distal to the insertions of
the flexor and extensor tendons.3
Fibrous septa located within the pulp
of the finger stabilize the vascular fi-
brofatty tissue and bridge the dermis
to the periosteum of the distal pha-
lanx.4 The nail bed, which has a con-
voluted attachment to the periosteum
of the distal phalanx, resists traumatic
avulsion. In humans, the fingernail
protects the fingertip and enhances its
dexterity and sensation by exerting
counterpressure for the volar pulp
during touch and facilitating skilled
hand function, such as the ability
to pick up and manipulate small
objects.5
The nailbed comprises germinal and
sterile matrices, with the germinal
matrix located on the palmar aspect of
the nail fold and terminating at the
distal extent of the lunula. This matrix
is more vascular than the remainder of
the nail bed and produces nearly all of
the nail via gradient parakeratosis.4
Near the periosteum, germinal matrix
cells originate as basilar cells. They
duplicate and are driven dorsally in
columns toward the nail. The cells

March 2014, Vol 22, No 3 165

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Acute and Chronic Paronychia of the Hand

Figure 1
Hyponychium

Nail plate
with sterile
matrix below

Paronychium
Lunula
Nail bed Insertion of
Nail vest extensor tendon
Nail fold Nail plate
with germinal Sterile matrix Germinal matrix
matrix below
Eponychium Dorsal
floor Nail
Ventral fold
floor
DIP joint

Hyponychium

A B

Illustrations of dorsal (A) and cross-section (B) views of the anatomy of the fingertip and nail bed. DIP = distal
interphalangeal

flatten and stream distally when they
meet the resistance of the nail, leading
to longitudinal nail growth.4 The nail
bed and the nail plate are involved in
the continuum of nail production at all
stages.
The sterile matrix lies distal to the
lunula. Its contribution to nail pro-
duction varies. Cells that originate
from the sterile matrix enlarge, flatten,
and elongate; large cells eventually
break down and are incorporated into
the nail. In most people, the nail is
thicker distally than proximally, pro-
viding evidence of the contribution of
the sterile matrix to nail production.
The nail plate is anchored to the
underlying linear ridges in the squa-
mous epithelium of the sterile matrix.4
The nail adheres less to the germinal
matrix than to the sterile matrix.
The paronychium is defined as the
soft tissue lateral to the nail bed,
whereas the term perionychium refers
to the paronychium and nail bed6
(Figure 1). Primate studies suggest that
after nail removal, the sterile matrix
contributes little to nail regeneration
and the nail is primarily reformed by
the paronychium.7 The junction where
the sterile matrix of the distal nail bed
meets the skin of the fingertip is called
the hyponychium. A keratinous plug
with abundant neutrophils and lym-
phocytes composes the hyponychium,
which serves as a barrier in preventing
microbial invasion of the subungual
area.4 The nail fold is an anatomic
transition between the nail bed and the
paronychium. The eponychium lies at
the most distal and dorsal portion of
the nail fold; this is where the nail fold
attaches to the surface of the nail. At
this junction, the nail vest (a thin veil of
tissue) is formed.
Acute Paronychia
Etiology and Risk Factors
Most acute paronychias are the result
of minor trauma to the nail bed that is
often related to onychophagia (ie, nail
biting), finger sucking, picking at
a hangnail, an ingrown nail, man-
icures, dishwashing, or puncture-type
trauma with or without a retained
foreign body. Such trauma disrupts the
fingertip’s natural barrier to outside
pathogens, resulting in inoculation of
the perionychium. In three studies with
a total of 61 patients with paronychia,
approximately 25% of paronychias
were caused by anaerobic bacteria,
25% by aerobic bacteria, and 50%
by mixed aerobic and anaerobic bac-
teria.8-10 The most common aerobic
pathogens responsible for acute par-
onychia include Staphylococcus
aureus, gamma-hemolytic strepto-
cocci, Eikenella corrodens, group A
b-hemolytic streptococci, and Klebsi-
ella pneumoniae.8 Common anaerobic
bacteria responsible for paronychia
include Bacteroides species, gram-pos-
itive anaerobic cocci, and Fusobacteria
species.8 Enterococcus faecalis, Pro-
teus species, and Pseudomonas aer-
uginosa are other isolated organisms
that can cause paronychia.8 In addi-
tion, nonbacterial pathogens such as
yeast (Candida albicans) and viruses
(eg, herpes simplex) have been iden-
tified as causative organisms. A spe-
cific trauma or inciting event may
not be identified in all cases of acute
paronychia.

166 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

Figure 2
A, Photograph of a fingertip
demonstrating an acute paronychia
and its sequelae. The patient
presented with acute onset of pain and
swelling. The abscess spontaneously
decompressed under the nail fold and
nail plate. B, Photograph of the
fingertip obtained 3 weeks later. The
infection resolved and a new nail is
growing to replace the one present at
the time of infection.
Clinical Presentation
Patients with acute paronychias typ-
ically present with localized pain,
redness, inflammation, and edema of
the paronychium that is typically
limited to a single digit. The timing of
presentation varies, but is often 2 to
5 days after the initial trauma. Fluc-
tuance of the paronychium may not
be observed with early presentation.
In patients with delayed presentation,
fluctuance may extend around the
nail, involving the eponychium as
well as the paronychium on both the
radial and ulnar sides of the digit (ie,
runaround infection). Purulence may
develop underneath the nail plate,
causing the nail plate to pull away
from the sterile matrix; this may be
more accurately described as a peri-
onychial infection (Figure 2).
Diagnosis
Diagnosis of acute paronychia is
based on the patient’s history and
physical examination. A detailed
history is crucial for evaluation of risk
factors that may be associated with
an atypical causative organism. For
example, contact with oral secretions
March 2014, Vol 22, No 3
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Shafritz, MD, and Jeff M. Coppage, MD
Figure 3
Photograph of a fingertip
demonstrating an abscess, which
is evident from the blanched area
caused by simple digital pinch
pressure. (Courtesy of Robert
Strauch, MD, New York, NY.)
may provide exposure to specific
anaerobic bacteria such as Eikenella
corrodens or the herpes virus. Expo-
sure to animals may result in an
increased risk of infection with gram-
negative organisms such as Pasteurella
multocida.
Turkmen et al11 described the use of
a digital pressure test to identify the
presence and extent of paronychial
abscesses. The test is performed by
applying light pressure to the distal
volar aspect of the affected digit and
observing for blanching in the area of
the paronychia (Figure 3). Blanching
may indicate the presence of an
abscess. Typically, radiographs and
laboratory tests are not needed for
diagnosis of acute paronychia.
Differential Diagnosis
Although gram-positive bacterial in-
fections account for most cases of
acute paronychia, a wide differential
should be considered. Herpetic whit-
low is a manifestation of herpes sim-
plex infection and presents as one or
more blisters grouped on the distal
Figure 4
Photograph of a fingertip
demonstrating herpetic whitlow.
(Reproduced with permission from
Usatine RP, Tinitigan R: Nongenital
herpes simplex virus. Am Fam
Physician 2010;82[9]:1075-1082.)
aspect of the digit12 (Figure 4). The
blisters are typically filled with serous-
type fluid, but the fluid may be more
opaque and can be easily mistaken for
purulence. Herpetic whitlow is often
seen in healthcare professionals (eg,
dental professionals) who are at risk
of topical exposure to the virus, but
the condition may also be seen in
persons with a primary herpes sim-
plex infection.13 A definitive diagnosis
is made based on Tzanck smear or
viral culture results. Incision and
drainage are contraindicated.
In addition, to herpetic whitlow,
other conditions such as psoriasis,
Reiter syndrome, and pemphigus
vulgaris can mimic acute or chronic
paronychia. Medications such as ret-
inoids, antiretrovirals, and chemo-
therapeutics can cause paronychial
inflammation, as well.
Nonsurgical Management
Management of paronychia depends
largely on the amount of inflamma-
tion and whether an abscess is pres-
ent. In patients who present with
a minimal amount of inflammation
and no abscess formation, frequent
soaks with warm water, aluminum
acetate (Burrow solution),14 vine-
gar,15 a dilute povidone-iodine
solution16 or chlorhexidine may be
sufficient. However, no studies have
167
 Acute and Chronic Paronychia of the Hand
Figure 5
A B
Illustrations demonstrating
decompression of an abscess using
a blade (A) or an elevator (B). The
paronychia is elevated from the nail
via the nail sulcus with care taken to
avoid injury to the nail bed.
evaluated the effectiveness of soaks
alone.
A topical antibiotic may be added
to the treatment regimen in patients
with minimal erythema and no
abscess formation. Topical and/or
oral antibiotics should be used in
patients with substantial erythema
and abscess formation. Topical an-
tibiotics may be used alone or in
combination with a corticosteroid.
Wollina17 compared the efficacy
of fusidic acid and betamethasone
versus gentamycin ointment for
acute paryonychia in a nonblinded
study. Erythema, swelling, exuda-
tion, and pain were graded on
a scale of 0 (absent) to 3 (heavy).
The author reported a 50% reduc-
tion in pain in the fusidic acid and
betamethasone group after 3.5 6
2.0 days compared with a 50%
reduction in pain after 5.1 6 3.1
days in the gentamycin group. Both
regimens were effective and had no
associated complications.
Oral antibiotic regimens such
as trimethoprim-sulfamethoxazole,
cephalexin, amoxicillin and clav-
ulanate, or clindamycin (in patients
168
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
with sensitivity to penicillins) should
provide coverage against gram-posi-
tive organisms, including S aureus
and streptococci.1 Tosti and Ilyas18
recommend the use of agents that
are effective against methicillin-
resistant S aureus, such as oral tri-
methoprim-sulfamethoxazole, if this
bacterium has been documented
in .10% of community-acquired
hand infections at a given institu-
tion. In the setting of suspected
infection with oral flora, broad-
spectrum antibiotics such as amox-
icillin/clavulanate or clindamycin
should be used to provide coverage
against anaerobic bacteria.1
Surgical Management
In general, surgical management of
acute paronychia is reserved for pa-
tients with a discrete abscess, failure of
nonsurgical care, and/or extensive
involvement of the eponychium.
Numerous surgical techniques have
been described for management of
acute paronychia, and each technique
has a role based on the structures
affected and the extent of involvement.
To our knowledge, no studies have
compared the efficacy of adminis-
tering oral antibiotics alone versus
drainage.19 Some authors recom-
mend a course of oral antibiotics
after drainage,20 whereas others
recommend drainage and local
wound care alone.2 No studies have
compared the efficacy of adminis-
tering oral antibiotics after drainage
with that of drainage and wound
care alone.
To drain an abscess, a No. 11 or 15
scalpel blade (with sharp edge
pointed away from the nail), a freer
elevator, or a small hemostat is in-
serted into the nail sulcus and beneath
the nail fold until the abscess is de-
compressed (Figure 5). This obviates
the need to create a skin incision in
the lateral nail fold, which can put
the intervening tissue at risk for skin
bridge necrosis.21 However, this
treatment option requires that the
Journal of the American Academy of Orthopaedic Surgeons
abscess be immediately adjacent to
the nail sulcus. A piece of mesh gauze
may be placed beneath the nail fold
to allow for continued drainage.21
Ogunlusi et al22 described a more
limited approach for draining an
abscess. The tip of a 21- or 23-gauge
needle is used to lift the nail
fold, allowing egress of purulence.
Drainage is followed by oral antibi-
otic therapy. The authors used
this technique in 8 patients with 10
paronychias and noted resolution of
acute paronychia in all patients after
2 days. The authors concluded that
neither anesthesia nor daily dressing
changes were required with this
technique.
Extensive abscesses or those not
immediately adjacent to the nail sulcus
may require the creation of skin in-
cisions to promote drainage. A small
incision made in the paronychium
directly over the abscess can facilitate
drainage (Figure 6). The sharp edge of
the blade should be pointed away
from the nail to avoid injury to the
matrix, which can lead to subsequent
nail deformity. Alternatively, a longi-
tudinal incision can be made in line
with the lateral nail fold to decom-
press the abscess.15 In the setting of
eponychia or runaround infection,
longitudinal incisions can be made on
both sides of the nail. If incisions are
made in line with the nail folds, the
fold can be reflected proximally, irri-
gated, and returned to its original
position (Figure 7). A piece of gauze
may be placed under the nail fold to
facilitate continued drainage. In
cases in which the abscess has
spread beneath the nail plate to
form a subungual abscess, partial
or complete removal of the nail
plate may be indicated, particularly
if the paronychia is related to an
ingrown nail. Complete removal of
the nail plate is reserved for cases in
which spreading infection has under-
mined the entire plate, causing com-
plete separation of the nail plate from
the underlying sterile matrix.
 Adam B. Shafritz, MD, and Jeff M. Coppage, MD

Figure 6

Photographs demonstrating decompression of an abscess adjacent to the paronychium of the thumb. The thumb is
anesthetized using a digital block. A, The area of fluctuance is incised. B, The abscess is decompressed. C, A probe is used
to break up any loculations. (Courtesy of Jeffrey Yao, MD, Redwood City, CA.)

Treatment failure and recurrence are Figure 7

uncommon after appropriate manage-
ment of acute paronychia. Failure to
recognize a significant abscess or
incomplete drainage or débridement
may result in persistent or recurrent
infection. Local factors such as the
extent of infection or host factors (eg,
diabetes mellitus, other immunocom-
promised states) may play a role in
impaired clearance of infection; how-
ever, no studies have demonstrated the
role of host factors with respect to acute
paronychia. Several studies cite treat-
ment failure as a risk factor for the A B C
development of chronic paronychia,
but sparse evidence has been Illustrations demonstrating management of acute paryonchia with eponychial
reported with regard to factors that involvement via reflection of the proximal nail fold. A, Two parallel incisions are
contribute to failed management of made in line with the nail fold. The nail fold is elevated (B) and gauze packing is
placed underneath it (C).
acute paronychia. To our knowl-
edge, no evidence exists to suggest
that improper management of and often is related to repeated handlers, swimmers, and nurses are
paronychial infection leads to felons exposure to environmental irri- commonly identified as having an
or osteomyelitis. tants, with colonization by fungal increased risk of chronic paronychia.21
or bacterial pathogens that occurs Conditions such as diabetes melli-
after disruption of the barrier tus and immunosuppression also
Chronic Paronychia formed by the eponychium and nail predispose patients to development
vest. Exposure to irritants can take of chronic paronychia.15
many forms and persons with C albicans is a pathogen commonly
Etiology and Risk Factors a higher risk of chronic paronychia associated with chronic paronychia;
Chronic paronychia is inflamma- include those with frequent exposure this fungus has been found in cultures
tion of the perionychium that has to moisture and/or chemical irri- in 40% to 95% of cases.2,15,23,24 The
been present for .6 weeks. This tants.23 Homemakers, bartenders, exact role that it plays in the devel-
inflammation can have many causes barbers, dishwashers, cooks, food opment and maintenance of chronic

March 2014, Vol 22, No 3 169

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Acute and Chronic Paronychia of the Hand
Figure 8
Lateral (A) and dorsal (B) photographs of the thumb demonstrating chronic
paronychia. Note that the nail is thickened, yellowed, ridged, and rounded.
paronychia is unclear. The presence
of Candida may represent a second-
ary colonization of the nail fold that
can contribute to the development
of chronic paronychia by inducing
an additional persistent inflamma-
tory response. In a study of chronic
paronychia, Stone and Mullins25
soaked fingers in water until they
were macerated and then inoculated
the perionychium with either viable
or nonviable Candida. Inflamma-
tory conditions similar to chronic
paronychia developed in both
groups, demonstrating the inflam-
matory effect caused by the patho-
gen. Tosti et al24 compared the use
of topical steroids versus systemic
antifungals for management of chronic
paronychia and found that the patients
treated with topical corticosteroid
alone showed more clinical improve-
ment than those treated with anti-
fungal agents alone. Eradication of
Candida was associated with cure in
only 2 of 18 patients who tested
positive for infection at the outset
of the study. The authors concluded
that, in patients with chronic par-
onychia, Candida is a secondary
colonizer of the nail fold, and chronic
paronychia is an inflammatory dis-
order rather than a primary mycotic
infection.
170
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Presentation and
Diagnosis
Typically, a thorough history and
physical examination is sufficient
to diagnose chronic paronychia. The
patient’s history typically reveals
exposure to one or more risk factors.
Chronic paronychia presents with
erythema, swelling, and pain,
although the degree of erythema and
swelling is often less than that asso-
ciated with acute paronychia.15 In
general, symptoms are present for .6
weeks at the time of diagnosis. Epi-
sodic exacerbation of symptoms
can occur, and such episodes may
follow exposure to moist environ-
ments.15 The proximal nail fold
may become raised and separated
from the underlying nail. Chronic
paronychia may have associated
nail changes including ridging,
grooving, discoloration, and/or
rounding of the nail plate (Figure
8). Further diagnostic testing may
be warranted in atypical cases in
which malignancy or systemic eti-
ologies are suspected.
Differential Diagnosis
Certain antiretroviral and chemother-
apeutic medications have been impli-
cated in the development of acute
Journal of the American Academy of Orthopaedic Surgeons
and chronic paronychia.26-31 Anti-
retroviral medications (eg, indinavir,
lamivudine), have been associated
with the development of paronychia
and periungual pyogenic granulo-
mas.32-34 The toes are often involved
but finger involvement has been
described, as well.32,34 The similarity
between the cutaneous side effects
associated with protease inhibitors
and those associated with retinoid-
based therapies have led to the the-
ory that protease inhibitors alter
retinoid metabolism, resulting in
the aforementioned cutaneous side
effects. Toma et al34 found that
indinavir and several other protease
inhibitors can significantly increase
plasma retinoic acid concentrations.
Some of the proposed mechanisms
include enhanced conversion of retinol
to retinoic acid caused by an in-
dinavir-mediated increase in the
activity and/or expression of retinal
dehydrogenase, inhibition of cyto-
chrome P450-mediated catabolism
of retinoic acid, and/or increased
activity of retinoid-responsive gene
products. 34 Anti-epidermal growth
factor receptor (EGFR) chemothera-
peutic agents (eg, cetuximab, gefitinib,
lapatinib) have been associated with
the development of paronychia, as
well.28,31,35 The inhibition of EGFR
by anti-EGFR agents has been impli-
cated in the development of chronic
paronychia.28
Malignancies of the periungual
region and paraneoplastic conditions
may mimic acute or chronic par-
onychia. Several conditions cause
a paronychia-like presentation,
including squamous cell carci-
noma,36,37 melanoma,38 Kaposi
sarcoma,39 digital papillary adeno-
carcinoma,40 myeloma-associated
systemic amyloidosis,41 bronchogenic
carcinoma,42 renal cell carcinoma,43
subungual keratoacanthoma, and
leukemia cutis.44 These diagnoses
should be considered in patients who
present with signs and symptoms of
paronychia, particularly in those with

recalcitrant paronychia or those with
a history of cancer.
Nonsurgical Management
The first step in management of
chronic paronychia is avoiding irri-
tants and moisture. Topical and sys-
temic therapies can be used, as
well.21,23,24,45,46 Tosti et al24 per-
formed a double-blind randomized
controlled trial to compare the
effectiveness of systemic antifungal
medications (250 mg of terbinafine
daily or 200 mg of itraconazole
daily) with that of a topical cortico-
steroid (0.1% 5 mg of methylpred-
nisolone aceponate daily). A placebo
was provided for each group. The
treatment period lasted 3 weeks. At 3
weeks, the authors noted a signifi-
cant increase in the clinical cure rate
of the topical corticosteroid group
compared with that of the antifungal
group (P , 0.01). The authors
reported improved or cured par-
onychia in 42 of 48 nails (87.5%) in
the corticosteroid group compared
with 22 of 64 nails (34.4%) in
the itraconazole group and 19 of
57 nails (33.3%) in the terbinafine
group. Tosti et al24 concluded that
topical corticosteroid therapy should
be used as a first-line treatment for
chronic paronychia. They also rec-
ommended that chronic paronychial
infection should be regarded as an
inflammatory disorder of the nail
fold rather than an onychomycosis.
In a study of 17 patients with
chronic paronychia, Daniel et al45 re-
ported good results with a combined
irritant avoidance regimen and topi-
cal application of a 0.77% ciclopirox
suspension, a broad-spectrum anti-
fungal with anti-inflammatory prop-
erties,47 for 6 to 12 weeks. Chronic
paronychia resolved in all 17 pa-
tients. The authors recommended
management of primary factors (eg,
exposure, irritants, inflammation)
and secondary fungal colonization to
reduce recurrence and avoid treat-
ment failure caused by the inflam-
March 2014, Vol 22, No 3
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Shafritz, MD, and Jeff M. Coppage, MD
matory effects of secondary fungal
colonization. The addition of a topi-
cal antifungal agent to topical corti-
costeroid therapy has been described;
however, the use of a topical anti-
fungal and corticosteroid has not
been shown to be superior to the use
of a topical corticosteroid alone.
In a study of 45 patients with
chronic paronychia, Rigopoulos
et al46 compared the safety and effi-
cacy of twice-daily application of
0.1% betamethasone 17-valerate
ointment with application of 0.1%
tacrolimus ointment or an unmedi-
cated emollient over a 3-week
period. Both the betamethasone and
tacrolimus groups demonstrated
statistically significant improvement
(P , 0.001) in cure or improvement
rate versus the emollient group, with
tacrolimus therapy demonstrating
the highest efficacy. Thus, a 1- to 2-
week course of 0.05% betametha-
sone cream or 0.1% betamethasone
solution or lotion has been recom-
mended for management of chronic
paronychia.1 For refractory cases of
chronic paronychia, some authors
have recommend a trial of a systemic
antifungal before proceeding with an
invasive procedure.1 In an earlier
study on paronychia, Rigopoulos
et al1 described the use of a short
course of systemic corticosteroids for
patients with severe involvement of
multiple fingers.
Surgical Management
Surgical management of chronic par-
onychia is typically reserved for
refractory cases. Several surgical
techniques have been described and
involve excision or elevation of the
involved tissue of the eponychium.
Chronic inflammation of the epo-
nychium leads to progressive fibrosis,
edema, induration, and rounding of
the cuticle border, which act together
to compromise the natural barrier
function and impair blood flow to the
affected tissues, making spontaneous
healing difficult.48,49
In 1976, Keyser and Eaton48
described the use of eponychial
marsupialization for management of
chronic paronychia. The original
technique involved excision of
a crescent-shaped area of the dorsal
aspect of the proximal nail fold
without concomitant nail removal.
The excision area begins 1 mm from
the distal border of the eponychium
and extends approximately 6 mm
proximally and from one lateral nail
fold to the other to include all in-
flamed tissue. Excision is followed
by hydrogen peroxide soaks and
dressing changes until reepitheliali-
zation occurs (typically within 2
weeks). The authors noted excellent
results with this technique, with
chronic paronychia cured in 28 of
31 digits. The exact mechanism by
which marsupialization promotes
healing is not well understood.
In 1981, Baran and Bureau50
described a technique that involved en
bloc excision of the proximal nail fold
without nail plate removal. A 5- to
6-mm–wide section of involved epo-
nychial tissue spanning from one lat-
eral nail fold to the other was excised
and, in contrast to marsupialization,
a distal rim of tissue was not spared.
After en bloc excision, postoperative
care consisted of dressing changes and
application of a topical antibiotic
preparation. The proposed benefit is
a simpler and more effective technique
than marsupialization with concomi-
tant nail plate removal that provides
satisfactory functional and cosmetic
results. However, objective outcome
data were not provided in the study.
In a long-term study of 25 patients
(28 fingers) with chronic paronychia
treated with eponychial marsupializa-
tion with or without nail removal,
Bednar and Lane51 reported better re-
sults in the group that underwent
simultaneous removal of the nail plate
(Figure 9). Of the 23 patients with nail
irregularities, the first seven were
treated with eponychial marsupializa-
tion without nail removal. Two of
171
 Acute and Chronic Paronychia of the Hand

Figure 9 Grover et al49 examined the effec-

tiveness of en bloc excision of the
proximal nail fold with and without
nail removal for management of
chronic paronychia. En bloc excision
of the proximal nail fold was per-
formed followed by a 5- to 7-day
course of oral antibiotics as well
as daily cleansing with antibiotic
solution and application of topical
antibacterial, antifungal, and corti-
costeroid creams. Of 30 patients, 12
in group I (en bloc excision without
nail removal) and 13 in group II (en
bloc excision with nail removal)
completed the treatment protocol.
The authors reported that 70% of
patients in group II were cured ver-
sus only 41% in group I.
Photographs of a finger before (A) and after (B) eponychial marsupialization
with nail removal. A, A small, crescent-shaped area proximal to the
Pabari et al52 described the use of
eponychium is marked for excision. B, The crescent of inflamed tissue is the Swiss roll technique for manage-
excised and the nail plate is removed. (Courtesy of Daniel Zlotolow, MD, ment of both acute and chronic par-
Philadelphia, PA.) onychias with runaround infection of
both nail folds. The eponychium is
these patients had a recurrence. The underlying fat and subcutaneous tissue elevated by making an incision on
remaining 16 patients underwent were left in place. In addition to both sides of the nail fold and then the
marsupialization with nail removal, marsupialization, all patients were eponychium is reflected proximally.
with no recurrence reported (P , treated with hydrogen peroxide soaks The wound is irrigated and the fold is
0.05). This technique differed slightly followed by cleansing with chlorhex- rolled back over a roll of nonadherent
from the technique described by Key- idine gluconate and, in patients with gauze dressing and then anchored
ser and Eaton48 in that a 3-mm cres- positive cultures, oral antibiotics for in place with nonabsorbable sutures
cent of tissue was excised and the 14 days or until cultures were negative. (Figure 10). Postoperative application

Figure 10

Intraoperative photograph (A) and illustration (B) demonstrating the Swiss roll technique for management of an acute
paronychia. A, The nail fold is incised, reflected, and rolled over nonadherent gauze. B, The edge of the nail fold is
anchored with nonabsorbable sutures. (Panel A reproduced with permission from Pabari A, Iyer S, Khoo CT: Swiss roll
technique for treatment of paronychia. Tech Hand Up Extrem Surg 2011;15[2]:75-77.)

172 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

of topical medications, either anti-
biotics or steroids, was not described.
The dressing and anchoring sutures
were removed 2 to 7 days post-
operatively. The nail fold was allowed
to return to its original position and
heal by secondary intention. Proposed
benefits of this technique include the
ability to retain the nail and to avoid
creating a skin defect. The authors
achieved “excellent cure rates” with
this technique.
With regard to treatment failure or
recurrence of symptoms after treat-
ment, a paucity of data are available.
This is partly due to variability in
reporting outcomes as improved
versus cured. In a study of patients
treated with marsupialization with
or without nail removal, Bednar and
Lane51 reported two recurrences in
the group that did not undergo nail
removal. Both recurrences were
treated with marsupialization with
nail removal. One went on to cure
and the other had persistent nail
deformity and tenderness. No re-
currences or treatment failures were
reported in the group treated with
marsupialization with nail removal.
Daniel et al45 treated simple chronic
paronychia with a combined regi-
men of ciclopirox and irritant
avoidance and reported a cure rate
of 100%. Although the authors
found that the use of a topical
antifungal was effective for pre-
venting recurrence of chronic par-
onychia, no control group was
available for comparison.
Studies have emphasized irritant
avoidance as a key factor in achieving
satisfactory results in management
of chronic paronychia.1,2,14,15,21,45
When patients are unable or
unwilling to comply with this rec-
ommendation, treatment failure is
likely. However, a thorough evalu-
ation should be performed in recal-
citrant cases of chronic paronychia
to rule out atypical etiologies such as
the use of specific medications (eg,
antiretrovirals) or malignancies.
March 2014, Vol 22, No 3
Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Shafritz, MD, and Jeff M. Coppage, MD
Summary
Acute and chronic paronychias of the
hand caused by infections are com-
mon. Acute paronychia typically
indicates an acute bacterial infection.
Cases without an associated abscess
often can be treated successfully with
an oral antibiotic regimen and soaks.
The presence of an abscess is an indi-
cation for surgical drainage, which can
be accomplished through various
techniques based on the extent of
infection, presence of an ingrown nail
or subungual abscess, and surgeon
preference. Further research is needed
to determine whether oral antibiotic
therapy is needed in addition to surgi-
cal drainage. Therefore, the decision to
prescribe antibiotic therapy after
drainage is based on clinical judgment
and the extent of infection.
Chronic paronychias represent per-
sistent inflammation of the nail fold that
is multifactorial in origin. Exposure to
environmental and occupational irri-
tants appears to be the primary cause of
this clinical entity, with secondary fun-
gal colonization common and a likely
contributor to ongoing inflammation.
Management of chronic paronychia
begins with avoidance of irritants and
topical anti-inflammatory medication.
The addition of topical antifungal
agents has been recommended; how-
ever, this is controversial.
Surgical management is reserved
for refractory cases of paronychia.
Several surgical procedures have been
described, with good to excellent re-
sults reported. Nail removal in con-
junction with tissue excision seems to
portend better results. Larger, pro-
spective studies are needed to identify
a treatment regimen that is clearly
superior for management of acute and
chronic paronychias.
Acknowledgment
The authors would like to thank
Robert Strauch, MD, Jeffrey Yao, MD,
and Daniel Zlotolow, MD, for pro-
viding photographs from their per-
sonal collections for this article.
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