Acute and Chronic Paronychia

 

Am Fam Physician. 2017 Jul 1;96(1):44-51.

  Patient information: See related handout on paronychia, written by the author of this article.

Author disclosure: No relevant financial affiliations.

Paronychia is inflammation of the fingers or toes in one or more of the three nail folds. Acute paronychia is caused by polymicrobial infections after the protective nail barrier has been breached. Treatment consists of warm soaks with or without Burow solution or 1% acetic acid. Topical antibiotics should be used with or without topical steroids when simple soaks do not relieve the inflammation. The presence of an abscess should be determined, which mandates drainage. There are a variety of options for drainage, ranging from instrumentation with a hypodermic needle to a wide incision with a scalpel. Oral antibiotics are usually not needed if adequate drainage is achieved unless the patient is immunocompromised or a severe infection is present. Therapy is based on the most likely pathogens and local resistance patterns. Chronic paronychia is characterized by symptoms of at least six weeks' duration and represents an irritant dermatitis to the breached nail barrier. Common irritants include acids, alkalis, and other chemicals used by housekeepers, dishwashers, bartenders, florists, bakers, and swimmers. Treatment is aimed at stopping the source of irritation while treating the inflammation with topical steroids or calcineurin inhibitors. More aggressive techniques may be required to restore the protective nail barrier. Treatment may take weeks to months. Patient education is paramount to reduce the recurrence of acute and chronic paronychia.

Paronychia is defined as inflammation of the fingers or toes in one or more of the three nail folds. The condition can be acute or chronic, with chronic paronychia being present for longer than six weeks. Although both result from loss of the normal nail-protective architecture, their etiologies are different, thus their treatments differ. Infections are responsible for acute cases, whereas irritants cause most chronic cases.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography can be used to determine the presence of an abscess or cellulitis when it is not clinically evident.

C

1012

The addition of topical steroids to topical antibiotics decreases the time to symptom resolution in acute paronychia.

B

19

Oral antibiotics are not needed when an abscess has been appropriately drained.

C

25, 26

Chronic paronychia is treated by topical anti-inflammatory agents and avoidance of irritants. Antifungals should not be used.

C

1, 29


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Ultrasonography can be used to determine the presence of an abscess or cellulitis when it is not clinically evident.

C

1012

The addition of topical steroids to topical antibiotics decreases the time to symptom resolution in acute paronychia.

B

19

Oral antibiotics are not needed when an abscess has been appropriately drained.

C

25, 26

Chronic paronychia is treated by topical anti-inflammatory agents and avoidance of irritants. Antifungals should not be used.

C

1, 29


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN EMERGENCY MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.

American College of Emergency Physicians


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN EMERGENCY MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.

American College of Emergency Physicians


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendation

The Author

JEFFREY C. LEGGIT, MD, CAQSM, is an associate professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

Author disclosure: No relevant financial affiliations.

Address correspondence to Jeffrey C. Leggit, MD, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814 (e-mail: jeff.leggit@usuhs.edu). Reprints are not available from the author.

REFERENCES

show all references

1. Shafritz AB, Coppage JM. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014;22(3):165–174....

2. Chang P. Diagnosis using the proximal and lateral nail folds. Dermatol Clin. 2015;33(2):207–241.

3. Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician. 2009;79(4):303–308.

4. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001;63(6):1113–1116.

5. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008;77(3):339–346.

6. Fowler JR, Ilyas AM. Epidemiology of adult acute hand infections at an urban medical center. J Hand Surg Am. 2013;38(6):1189–1193.

7. Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316(3):325–337.

8. Choosing Wisely Campaign. http://www.choosingwisely.org/clinician-lists/american-college-emergency-physicians-antibiotics-wound-cultures-in-emergency-department-patients/. Accessed August 11, 2016.

9. Biesbroeck LK, Fleckman P. Nail disease for the primary care provider. Med Clin North Am. 2015;99(6):1213–1226.

10. Adhikari S, Blaivas M. Sonography first for subcutaneous abscess and cellulitis evaluation. J Ultrasound Med. 2012;31(10):1509–1512.

11. Alsaawi A, Alrajhi K, Alshehri A, Ababtain A, Alsolamy S. Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: a systematic review of the literature. Eur J Emerg Med. Published online ahead of print October 19, 2015. http://journals.lww.com/euro-emergencymed/Citation/2017/06000/Ultrasonography_for_the_diagnosis_of_patients_with.3.aspx (subscription required). Accessed February 1, 2017.

12. Marin JR, Dean AJ, Bilker WB, Panebianco NL, Brown NJ, Alpern ER. Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med. 2013;20(6):545–553.

13. Turkmen A, Warner RM, Page RE. Digital pressure test for paronychia. Br J Plast Surg. 2004;57(1):93–94.

14. Marx J, Hockberger R, Walls R, eds. Hand. In: Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, Pa.: Saunders; 2013:534–570.

15. Jinnouchi O, Kuwahara T, Ishida S, et al. Anti-microbial and therapeutic effects of modified Burow's solution on refractory otorrhea. Auris Nasus Larynx. 2012;39(4):374–377.

16. Nagoba BS, Selkar SP, Wadher BJ, Gandhi RC. Acetic acid treatment of pseudomonal wound infections—a review. J Infect Public Health. 2013;6(6):410–415.

17. Madhusudhan VL. Efficacy of 1% acetic acid in the treatment of chronic wounds infected with Pseudomonas aeruginosa prospective randomised controlled: clinical trial. Int Wound J. 2015;13(6):1129–1136.

18. Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008;58(1):1–21.

19. Wollina U. Acute paronychia: comparative treatment with topical antibiotic alone or in combination with corticosteroid. J Eur Acad Dermatol Venereol. 2001;15(1):82–84.

20. Ogunlusi JD, Oginni LM, Ogunlusi OO. DAREJD simple technique of draining acute paronychia. Tech Hand Up Extrem Surg. 2005;9(2):120–121.

21. Jellinek NJ, Vélez NF. Nail surgery: best way to obtain effective anesthesia. Dermatol Clin. 2015;33(2):265–271.

22. Latham JL, Martin SN. Infiltrative anesthesia in office practice. Am Fam Physician. 2014;89(12):956–962.

23. Pabari A, Iyer S, Khoo CT. Swiss roll technique for treatment of paronychia. Tech Hand Up Extrem Surg. 2011;15(2):75–77.

24. Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and soft tissue infections. Am Fam Physician. 2015;92(6):474–483.

25. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med. 2010;55(5):401–407.

26. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection [published correction appears in Ann Emerg Med. 2010;56(5):588]. Ann Emerg Med. 2010;56(3):283–287.

27. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus [published correction appears in N Engl J Med. 2007;357(13):1357]. N Engl J Med. 2007;357(4):380–390.

28. Tully AS, Trayes KP, Studdiford JS. Evaluation of nail abnormalities. Am Fam Physician. 2012;85(8):779–787.

29. Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002;47(1):73–76.

30. Habif TP. Nail disorders. In: Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 6th ed. Philadelphia, Pa.: Elsevier; 2016:960–985.

31. Lacouture ME, Anadkat MJ, Bensadoun RJ, et al.; MASCC Skin Toxicity Study Group. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer. 2011;19(8):1079–1095.

32. Capriotti K, Capriotti JA, Lessin S, et al. The risk of nail changes with taxane chemotherapy: a systematic review of the literature and meta-analysis. Br J Dermatol. 2015;173(3):842–845.

33. 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(4):858–860.

34. Capriotti K, Capriotti JA. Chemotherapy-associated paronychia treated with a dilute povidone-iodine/dimethylsulfoxide preparation. Clin Cosmet Investig Dermatol. 2015;8:489–491.

35. Iorizzo M. Tips to treat the 5 most common nail disorders: brittle nails, onycholysis, paronychia, psoriasis, onychomycosis. Dermatol Clin. 2015;33(2):175–183.

 

 

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