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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-


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

March 2014, Vol 22, No 3 165

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

Figure 2 Figure 3 Figure 4

Photograph of a fingertip
A, Photograph of a fingertip demonstrating herpetic whitlow.
demonstrating an acute paronychia (Reproduced with permission from
and its sequelae. The patient Usatine RP, Tinitigan R: Nongenital
presented with acute onset of pain and herpes simplex virus. Am Fam
swelling. The abscess spontaneously Physician 2010;82[9]:1075-1082.)
decompressed under the nail fold and
nail plate. B, Photograph of the
fingertip obtained 3 weeks later. The aspect of the digit12 (Figure 4). The
infection resolved and a new nail is Photograph of a fingertip blisters are typically filled with serous-
growing to replace the one present at demonstrating an abscess, which
the time of infection. is evident from the blanched area
type fluid, but the fluid may be more
caused by simple digital pinch opaque and can be easily mistaken for
pressure. (Courtesy of Robert purulence. Herpetic whitlow is often
Clinical Presentation Strauch, MD, New York, NY.) seen in healthcare professionals (eg,
Patients with acute paronychias typ- dental professionals) who are at risk
ically present with localized pain, may provide exposure to specific of topical exposure to the virus, but
redness, inflammation, and edema of anaerobic bacteria such as Eikenella the condition may also be seen in
the paronychium that is typically corrodens or the herpes virus. Expo- persons with a primary herpes sim-
limited to a single digit. The timing of sure to animals may result in an plex infection.13 A definitive diagnosis
presentation varies, but is often 2 to increased risk of infection with gram- is made based on Tzanck smear or
5 days after the initial trauma. Fluc- negative organisms such as Pasteurella viral culture results. Incision and
tuance of the paronychium may not multocida. drainage are contraindicated.
be observed with early presentation. Turkmen et al11 described the use of In addition, to herpetic whitlow,
In patients with delayed presentation, a digital pressure test to identify the other conditions such as psoriasis,
fluctuance may extend around the presence and extent of paronychial Reiter syndrome, and pemphigus
nail, involving the eponychium as abscesses. The test is performed by vulgaris can mimic acute or chronic
well as the paronychium on both the applying light pressure to the distal paronychia. Medications such as ret-
radial and ulnar sides of the digit (ie, volar aspect of the affected digit and inoids, antiretrovirals, and chemo-
runaround infection). Purulence may observing for blanching in the area of therapeutics can cause paronychial
develop underneath the nail plate, the paronychia (Figure 3). Blanching inflammation, as well.
causing the nail plate to pull away may indicate the presence of an
from the sterile matrix; this may be abscess. Typically, radiographs and Nonsurgical Management
more accurately described as a peri- laboratory tests are not needed for Management of paronychia depends
onychial infection (Figure 2). diagnosis of acute paronychia. largely on the amount of inflamma-
tion and whether an abscess is pres-
Diagnosis Differential Diagnosis ent. In patients who present with
Diagnosis of acute paronychia is Although gram-positive bacterial in- a minimal amount of inflammation
based on the patient’s history and fections account for most cases of and no abscess formation, frequent
physical examination. A detailed acute paronychia, a wide differential soaks with warm water, aluminum
history is crucial for evaluation of risk should be considered. Herpetic whit- acetate (Burrow solution),14 vine-
factors that may be associated with low is a manifestation of herpes sim- gar,15 a dilute povidone-iodine
an atypical causative organism. For plex infection and presents as one or solution16 or chlorhexidine may be
example, contact with oral secretions more blisters grouped on the distal sufficient. However, no studies have

March 2014, Vol 22, No 3 167

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Acute and Chronic Paronychia of the Hand

Figure 5 with sensitivity to penicillins) should abscess be immediately adjacent to


provide coverage against gram-posi- the nail sulcus. A piece of mesh gauze
tive organisms, including S aureus may be placed beneath the nail fold
and streptococci.1 Tosti and Ilyas18 to allow for continued drainage.21
recommend the use of agents that Ogunlusi et al22 described a more
are effective against methicillin- limited approach for draining an
resistant S aureus, such as oral tri- abscess. The tip of a 21- or 23-gauge
methoprim-sulfamethoxazole, if this needle is used to lift the nail
bacterium has been documented fold, allowing egress of purulence.
in .10% of community-acquired Drainage is followed by oral antibi-
hand infections at a given institu- otic therapy. The authors used
tion. In the setting of suspected this technique in 8 patients with 10
infection with oral flora, broad- paronychias and noted resolution of
A B
spectrum antibiotics such as amox- acute paronychia in all patients after
icillin/clavulanate or clindamycin 2 days. The authors concluded that
should be used to provide coverage neither anesthesia nor daily dressing
Illustrations demonstrating
decompression of an abscess using against anaerobic bacteria.1 changes were required with this
a blade (A) or an elevator (B). The technique.
paronychia is elevated from the nail Surgical Management Extensive abscesses or those not
via the nail sulcus with care taken to In general, surgical management of immediately adjacent to the nail sulcus
avoid injury to the nail bed.
acute paronychia is reserved for pa- may require the creation of skin in-
tients with a discrete abscess, failure of cisions to promote drainage. A small
nonsurgical care, and/or extensive incision made in the paronychium
evaluated the effectiveness of soaks involvement of the eponychium. directly over the abscess can facilitate
alone. Numerous surgical techniques have drainage (Figure 6). The sharp edge of
A topical antibiotic may be added been described for management of the blade should be pointed away
to the treatment regimen in patients acute paronychia, and each technique from the nail to avoid injury to the
with minimal erythema and no has a role based on the structures matrix, which can lead to subsequent
abscess formation. Topical and/or affected and the extent of involvement. nail deformity. Alternatively, a longi-
oral antibiotics should be used in To our knowledge, no studies have tudinal incision can be made in line
patients with substantial erythema compared the efficacy of adminis- with the lateral nail fold to decom-
and abscess formation. Topical an- tering oral antibiotics alone versus press the abscess.15 In the setting of
tibiotics may be used alone or in drainage.19 Some authors recom- eponychia or runaround infection,
combination with a corticosteroid. mend a course of oral antibiotics longitudinal incisions can be made on
Wollina17 compared the efficacy after drainage,20 whereas others both sides of the nail. If incisions are
of fusidic acid and betamethasone recommend drainage and local made in line with the nail folds, the
versus gentamycin ointment for wound care alone.2 No studies have fold can be reflected proximally, irri-
acute paryonychia in a nonblinded compared the efficacy of adminis- gated, and returned to its original
study. Erythema, swelling, exuda- tering oral antibiotics after drainage position (Figure 7). A piece of gauze
tion, and pain were graded on with that of drainage and wound may be placed under the nail fold to
a scale of 0 (absent) to 3 (heavy). care alone. facilitate continued drainage. In
The author reported a 50% reduc- To drain an abscess, a No. 11 or 15 cases in which the abscess has
tion in pain in the fusidic acid and scalpel blade (with sharp edge spread beneath the nail plate to
betamethasone group after 3.5 6 pointed away from the nail), a freer form a subungual abscess, partial
2.0 days compared with a 50% elevator, or a small hemostat is in- or complete removal of the nail
reduction in pain after 5.1 6 3.1 serted into the nail sulcus and beneath plate may be indicated, particularly
days in the gentamycin group. Both the nail fold until the abscess is de- if the paronychia is related to an
regimens were effective and had no compressed (Figure 5). This obviates ingrown nail. Complete removal of
associated complications. the need to create a skin incision in the nail plate is reserved for cases in
Oral antibiotic regimens such the lateral nail fold, which can put which spreading infection has under-
as trimethoprim-sulfamethoxazole, the intervening tissue at risk for skin mined the entire plate, causing com-
cephalexin, amoxicillin and clav- bridge necrosis.21 However, this plete separation of the nail plate from
ulanate, or clindamycin (in patients treatment option requires that the the underlying sterile matrix.

168 Journal of the American Academy of Orthopaedic Surgeons

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 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

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Acute and Chronic Paronychia of the Hand

Figure 8 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
Lateral (A) and dorsal (B) photographs of the thumb demonstrating chronic
paronychia. Note that the nail is thickened, yellowed, ridged, and rounded. indinavir and several other protease
inhibitors can significantly increase
plasma retinoic acid concentrations.
paronychia is unclear. The presence Clinical Presentation and Some of the proposed mechanisms
of Candida may represent a second- Diagnosis include enhanced conversion of retinol
ary colonization of the nail fold that to retinoic acid caused by an in-
Typically, a thorough history and
can contribute to the development dinavir-mediated increase in the
physical examination is sufficient
of chronic paronychia by inducing activity and/or expression of retinal
to diagnose chronic paronychia. The
an additional persistent inflamma- dehydrogenase, inhibition of cyto-
patient’s history typically reveals
tory response. In a study of chronic chrome P450-mediated catabolism
exposure to one or more risk factors.
paronychia, Stone and Mullins25 of retinoic acid, and/or increased
Chronic paronychia presents with
soaked fingers in water until they activity of retinoid-responsive gene
erythema, swelling, and pain,
were macerated and then inoculated products. 34 Anti-epidermal growth
although the degree of erythema and
the perionychium with either viable factor receptor (EGFR) chemothera-
swelling is often less than that asso-
or nonviable Candida. Inflamma- peutic agents (eg, cetuximab, gefitinib,
ciated with acute paronychia.15 In
tory conditions similar to chronic lapatinib) have been associated with
general, symptoms are present for .6
paronychia developed in both the development of paronychia, as
weeks at the time of diagnosis. Epi-
groups, demonstrating the inflam- well.28,31,35 The inhibition of EGFR
sodic exacerbation of symptoms
matory effect caused by the patho- by anti-EGFR agents has been impli-
can occur, and such episodes may
gen. Tosti et al24 compared the use cated in the development of chronic
follow exposure to moist environ-
of topical steroids versus systemic paronychia.28
ments.15 The proximal nail fold
antifungals for management of chronic Malignancies of the periungual
may become raised and separated
paronychia and found that the patients region and paraneoplastic conditions
from the underlying nail. Chronic
treated with topical corticosteroid may mimic acute or chronic par-
paronychia may have associated
alone showed more clinical improve- onychia. Several conditions cause
nail changes including ridging,
ment than those treated with anti- a paronychia-like presentation,
grooving, discoloration, and/or
fungal agents alone. Eradication of including squamous cell carci-
rounding of the nail plate (Figure
Candida was associated with cure in noma,36,37 melanoma,38 Kaposi
8). Further diagnostic testing may
only 2 of 18 patients who tested sarcoma,39 digital papillary adeno-
be warranted in atypical cases in
positive for infection at the outset carcinoma,40 myeloma-associated
which malignancy or systemic eti-
of the study. The authors concluded systemic amyloidosis,41 bronchogenic
ologies are suspected.
that, in patients with chronic par- carcinoma,42 renal cell carcinoma,43
onychia, Candida is a secondary subungual keratoacanthoma, and
colonizer of the nail fold, and chronic Differential Diagnosis leukemia cutis.44 These diagnoses
paronychia is an inflammatory dis- Certain antiretroviral and chemother- should be considered in patients who
order rather than a primary mycotic apeutic medications have been impli- present with signs and symptoms of
infection. cated in the development of acute paronychia, particularly in those with

170 Journal of the American Academy of Orthopaedic Surgeons

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Adam B. Shafritz, MD, and Jeff M. Coppage, MD

recalcitrant paronychia or those with matory effects of secondary fungal In 1976, Keyser and Eaton48
a history of cancer. colonization. The addition of a topi- described the use of eponychial
cal antifungal agent to topical corti- marsupialization for management of
Nonsurgical Management costeroid therapy has been described; chronic paronychia. The original
The first step in management of however, the use of a topical anti- technique involved excision of
chronic paronychia is avoiding irri- fungal and corticosteroid has not a crescent-shaped area of the dorsal
tants and moisture. Topical and sys- been shown to be superior to the use aspect of the proximal nail fold
temic therapies can be used, as of a topical corticosteroid alone. without concomitant nail removal.
well.21,23,24,45,46 Tosti et al24 per- In a study of 45 patients with The excision area begins 1 mm from
formed a double-blind randomized chronic paronychia, Rigopoulos the distal border of the eponychium
controlled trial to compare the et al46 compared the safety and effi- and extends approximately 6 mm
effectiveness of systemic antifungal cacy of twice-daily application of proximally and from one lateral nail
medications (250 mg of terbinafine 0.1% betamethasone 17-valerate fold to the other to include all in-
daily or 200 mg of itraconazole ointment with application of 0.1% flamed tissue. Excision is followed
daily) with that of a topical cortico- tacrolimus ointment or an unmedi- by hydrogen peroxide soaks and
steroid (0.1% 5 mg of methylpred- cated emollient over a 3-week dressing changes until reepitheliali-
nisolone aceponate daily). A placebo period. Both the betamethasone and zation occurs (typically within 2
was provided for each group. The tacrolimus groups demonstrated weeks). The authors noted excellent
treatment period lasted 3 weeks. At 3 statistically significant improvement results with this technique, with
weeks, the authors noted a signifi- (P , 0.001) in cure or improvement chronic paronychia cured in 28 of
cant increase in the clinical cure rate rate versus the emollient group, with 31 digits. The exact mechanism by
of the topical corticosteroid group tacrolimus therapy demonstrating which marsupialization promotes
compared with that of the antifungal the highest efficacy. Thus, a 1- to 2- healing is not well understood.
group (P , 0.01). The authors week course of 0.05% betametha- In 1981, Baran and Bureau50
reported improved or cured par- sone cream or 0.1% betamethasone described a technique that involved en
onychia in 42 of 48 nails (87.5%) in solution or lotion has been recom- bloc excision of the proximal nail fold
the corticosteroid group compared mended for management of chronic without nail plate removal. A 5- to
with 22 of 64 nails (34.4%) in paronychia.1 For refractory cases of 6-mm–wide section of involved epo-
the itraconazole group and 19 of chronic paronychia, some authors nychial tissue spanning from one lat-
57 nails (33.3%) in the terbinafine have recommend a trial of a systemic eral nail fold to the other was excised
group. Tosti et al24 concluded that antifungal before proceeding with an and, in contrast to marsupialization,
topical corticosteroid therapy should invasive procedure.1 In an earlier a distal rim of tissue was not spared.
be used as a first-line treatment for study on paronychia, Rigopoulos After en bloc excision, postoperative
chronic paronychia. They also rec- et al1 described the use of a short care consisted of dressing changes and
ommended that chronic paronychial course of systemic corticosteroids for application of a topical antibiotic
infection should be regarded as an patients with severe involvement of preparation. The proposed benefit is
inflammatory disorder of the nail multiple fingers. a simpler and more effective technique
fold rather than an onychomycosis. than marsupialization with concomi-
In a study of 17 patients with Surgical Management tant nail plate removal that provides
chronic paronychia, Daniel et al45 re- Surgical management of chronic par- satisfactory functional and cosmetic
ported good results with a combined onychia is typically reserved for results. However, objective outcome
irritant avoidance regimen and topi- refractory cases. Several surgical data were not provided in the study.
cal application of a 0.77% ciclopirox techniques have been described and In a long-term study of 25 patients
suspension, a broad-spectrum anti- involve excision or elevation of the (28 fingers) with chronic paronychia
fungal with anti-inflammatory prop- involved tissue of the eponychium. treated with eponychial marsupializa-
erties,47 for 6 to 12 weeks. Chronic Chronic inflammation of the epo- tion with or without nail removal,
paronychia resolved in all 17 pa- nychium leads to progressive fibrosis, Bednar and Lane51 reported better re-
tients. The authors recommended edema, induration, and rounding of sults in the group that underwent
management of primary factors (eg, the cuticle border, which act together simultaneous removal of the nail plate
exposure, irritants, inflammation) to compromise the natural barrier (Figure 9). Of the 23 patients with nail
and secondary fungal colonization to function and impair blood flow to the irregularities, the first seven were
reduce recurrence and avoid treat- affected tissues, making spontaneous treated with eponychial marsupializa-
ment failure caused by the inflam- healing difficult.48,49 tion without nail removal. Two of

March 2014, Vol 22, No 3 171

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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

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Adam B. Shafritz, MD, and Jeff M. Coppage, MD

of topical medications, either anti- and Daniel Zlotolow, MD, for pro-
biotics or steroids, was not described.
Summary viding photographs from their per-
The dressing and anchoring sutures sonal collections for this article.
Acute and chronic paronychias of the
were removed 2 to 7 days post-
hand caused by infections are com-
operatively. The nail fold was allowed
mon. Acute paronychia typically
to return to its original position and References
indicates an acute bacterial infection.
heal by secondary intention. Proposed
Cases without an associated abscess
benefits of this technique include the Evidence-based Medicine: Levels of
often can be treated successfully with
ability to retain the nail and to avoid evidence are described in the table of
an oral antibiotic regimen and soaks.
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The presence of an abscess is an indi-
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cation for surgical drainage, which can
this technique. References 23 and 25 are level III
be accomplished through various
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techniques based on the extent of
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cal drainage. Therefore, the decision to 5 years.
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March 2014, Vol 22, No 3 173

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