Paronychia and ingrown toenails
- Beth G Goldstein, MD
Beth G Goldstein, MD
- Adjunct Clinical Assistant Professor
- Department of Dermatology
- University of North Carolina at Chapel Hill
- Adam O Goldstein, MD, MPH
Adam O Goldstein, MD, MPH
- Department of Family Medicine
- University of North Carolina at Chapel Hill
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — Dermatology
- Associate Professor of Dermatology and Public Health
- Denver VA Medical Center, University of Colorado School of Medicine and Colorado School of Public Health
- Moise L Levy, MD
Moise L Levy, MD
- Section Editor — Pediatric Dermatology
- Clinical Professor of Dermatology and Pediatrics
- Baylor College of Medicine
- Professor of Medicine
- Dell Medical School/University of Texas, Austin
Paronychia is an inflammation involving the lateral and proximal fingernail folds. Predisposing factors include overzealous manicuring, nail biting, thumbsucking, diabetes mellitus, and occupations in which the hands are frequently immersed in water . Paronychia has also been reported in association with antiretroviral therapy for HIV infection [2,3], and with use of epidermal growth factor inhibitors .
Paronychia may be either acute or chronic.
●Acute paronychia is characterized by the onset of pain and erythema of the posterior or lateral nail folds, with subsequent development of a superficial abscess (picture 1A-C).
In digits without exposure to oral flora, acute paronychia is most commonly caused by skin flora (such as Staphylococcus aureus and Streptococcus pyogenes) .
In digits exposed to oral flora, acute paronychia may be caused by either skin or oral flora. In this setting, organisms include both aerobic bacteria (such as streptococci, S. aureus, and Eikenella corrodens) and anaerobic bacteria (such as Fusobacterium, Peptostreptococcus, Prevotella, and Porphyromonas spp) [6,7].
●Candida is frequently isolated from the proximal nail fold of patients with chronic paronychia (picture 2A-B) [8,9]. However, it is not clear that Candida infection is actually responsible for the onset and maintenance of the disease. On the other hand, there is substantial evidence that chronic paronychia represents an eczematous condition with a multifactorial etiology (see below) [10-13]. Acute bacterial paronychia can exacerbate the chronic swelling and erythema of the proximal nail fold associated with chronic paronychia.
Diagnosis — The clinical appearance of swollen, tender posterior or lateral nail folds should confirm the diagnosis of paronychia. A purulent fluid collection is often present in acute paronychia (picture 1A-C). Retraction of the proximal nail fold, loss of the cuticle, and nail dystrophy are common features of chronic paronychia (picture 2A-B).
- Shroff PS, Parikh DA, Fernandez RJ, Wagle UD. Clinical and mycological spectrum of cutaneous candidiasis in Bombay. J Postgrad Med 1990; 36:83.
- Alam M, Scher RK. Indinavir-related recurrent paronychia and ingrown toenails. Cutis 1999; 64:277.
- Tosti A, Piraccini BM, D'Antuono A, et al. Paronychia associated with antiretroviral therapy. Br J Dermatol 1999; 140:1165.
- Fox LP. Nail toxicity associated with epidermal growth factor receptor inhibitor therapy. J Am Acad Dermatol 2007; 56:460.
- Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician 2008; 77:339.
- Brook I. Paronychia: a mixed infection. Microbiology and management. J Hand Surg Br 1993; 18:358.
- Brook I. Bacteriologic study of paronychia in children. Am J Surg 1981; 141:703.
- Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001; 63:1113.
- Barlow AJ, Chattaway FW, Holgate MC, Aldersley T. Chronic paronychia. Br J Dermatol 1970; 82:448.
- Kanerva L. Occupational protein contact dermatitis and paronychia from natural rubber latex. J Eur Acad Dermatol Venereol 2000; 14:504.
- Tosti A, Guerra L, Morelli R, et al. Role of foods in the pathogenesis of chronic paronychia. J Am Acad Dermatol 1992; 27:706.
- Daniel CR 3rd, Daniel MP, Daniel CM, et al. Chronic paronychia and onycholysis: a thirteen-year experience. Cutis 1996; 58:397.
- 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; 47:73.
- Hengge UR, Bardeli V. Images in clinical medicine. Green nails. N Engl J Med 2009; 360:1125.
- Clark DC. Common acute hand infections. Am Fam Physician 2003; 68:2167.
- Wollina U. Acute paronychia: comparative treatment with topical antibiotic alone or in combination with corticosteroid. J Eur Acad Dermatol Venereol 2001; 15:82.
- Rigopoulos D, Gregoriou S, Belyayeva E, et al. 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.
- Connolly B, Fitzgerald RJ. Pledgets in ingrowing toenails. Arch Dis Child 1988; 63:71.
- Senapati A. Conservative outpatient management of ingrowing toenails. J R Soc Med 1986; 79:339.
- Heidelbaugh JJ, Lee H. Management of the ingrown toenail. Am Fam Physician 2009; 79:303.
- Daniel CR 3rd, Iorizzo M, Tosti A, Piraccini BM. Ingrown toenails. Cutis 2006; 78:407.
- Reyzelman AM, Trombello KA, Vayser DJ, et al. Are antibiotics necessary in the treatment of locally infected ingrown toenails? Arch Fam Med 2000; 9:930.
- Grieg JD, Anderson JH, Ireland AJ, Anderson JR. The surgical treatment of ingrowing toenails. J Bone Joint Surg Br 1991; 73:131.
- Eekhof JA, Van Wijk B, Knuistingh Neven A, van der Wouden JC. Interventions for ingrowing toenails. Cochrane Database Syst Rev 2012; :CD001541.
- Bostanci S, Kocyigit P, Gürgey E. Comparison of phenol and sodium hydroxide chemical matricectomies for the treatment of ingrowing toenails. Dermatol Surg 2007; 33:680.