- 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
- Antonella Tosti, MD
Antonella Tosti, MD
- Professor of Clinical Dermatology
- Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — General Dermatology
- Professor of Dermatology and Public Health
- University of Colorado School of Medicine
- Colorado School of Public Health
- Chief, Dermatology Service
- US Department of Veterans Affairs
- Eastern Colorado Health Care System
- Moise L Levy, MD
Moise L Levy, MD
- Section Editor — Pediatric Dermatology
- Professor of Pediatrics and Medicine (Dermatology)
- Dell Medical School, University of Texas, Austin
- Clinical Professor of Dermatology and Pediatrics
- Baylor College of Medicine
Paronychia is an inflammation involving the lateral and proximal nail folds. It may be acute (lasting for less than six weeks) or chronic (lasting for six weeks or longer) . Predisposing factors include overzealous manicuring, nail biting, picking at a hangnail, thumbsucking, ingrown nail, diabetes mellitus, and occupations in which the hands are frequently immersed in water . Paronychia has also been reported as an adverse effect of several drugs, including antiretroviral agents [3,4], systemic retinoids, epidermal growth factor receptor (EGFR) inhibitors, and cytotoxic chemotherapy agents [5,6].
This topic will discuss the pathogenesis, clinical manifestations, and management of acute and chronic paronychia. Ingrown toenails and other nail disorders are discussed separately. (See "Management of ingrown toenails" and "Overview of nail disorders" and "Nail psoriasis" and "Principles and overview of nail surgery" and "Nail avulsion and chemical matricectomy" and "Nail biopsy: Indications and techniques" and "Dermoscopy of nail pigmentations" and "Dermoscopy of nonpigmented nail lesions".)
Acute paronychia is an acute inflammatory process, with or without abscess formation, that involves the proximal and lateral nail folds and that has been present for less than six weeks [1,7]. Acute paronychia, often associated with periungual pyogenic granuloma-like lesions, has been reported in approximately 17 percent of patients treated with epidermal growth factor receptor (EGFR) inhibitors after two or more months of drug exposure .
Pathogenesis — Acute paronychia is most commonly caused by the inoculation of pathogens present in the skin flora (eg, Staphylococcus aureus, Streptococcus pyogenes) into the periungual tissues by minor mechanical or chemical traumas that disrupt the nail fold barrier . Common favoring factors include manicuring, nail biting, thumbsucking, picking at a hangnail, and ingrowing toenails.
Other organisms that may be occasionally involved, especially in acute episodes occurring in patients with chronic paronychia, include Pseudomonas aeruginosa and other Gram stain-negative bacteria. Acute paronychia of the toes occurs in most cases in association with ingrown toenails . (See "Management of ingrown toenails".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Shafritz AB, Coppage JM. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg 2014; 22:165.
- 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.
- Robert C, Sibaud V, Mateus C, et al. Nail toxicities induced by systemic anticancer treatments. Lancet Oncol 2015; 16:e181.
- Garden BC, Wu S, Lacouture ME. The risk of nail changes with epidermal growth factor receptor inhibitors: a systematic review of the literature and meta-analysis. J Am Acad Dermatol 2012; 67:400.
- Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician 2008; 77:339.
- Lomax A, Thornton J, Singh D. Toenail paronychia. Foot Ankle Surg 2016; 22:219.
- 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.
- Figueiras Dde A, Ramos TB, Marinho AK, et al. Paronychia and granulation tissue formation during treatment with isotretinoin. An Bras Dermatol 2016; 91:223.
- Blumental G. Paronychia and pyogenic granuloma-like lesions with isotretinoin. J Am Acad Dermatol 1984; 10:677.
- Durdu M, Ruocco V. Clinical and cytologic features of antibiotic-resistant acute paronychia. J Am Acad Dermatol 2014; 70:120.
- Sibel S, Macher A, Goosby E. Paronychia in patients receiving antiretroviral therapy for human immunodeficiency virus infection. J Am Podiatr Med Assoc 2000; 90:98.
- Colson AE, Sax PE, Keller MJ, et al. Paronychia in association with indinavir treatment. Clin Infect Dis 2001; 32:140.
- García-Silva J, Almagro M, Peña-Penabad C, Fonseca E. Indinavir-induced retinoid-like effects: incidence, clinical features and management. Drug Saf 2002; 25:993.
- Lipner SR, Scher RK. Congenital Malalignment of the Great Toenails With Acute Paronychia. Pediatr Dermatol 2016; 33:e288.
- Patel DB, Emmanuel NB, Stevanovic MV, et al. Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics 2014; 34:1968.
- Clark DC. Common acute hand infections. Am Fam Physician 2003; 68:2167.
- Turkmen A, Warner RM, Page RE. Digital pressure test for paronychia. Br J Plast Surg 2004; 57:93.
- Langley A, Asai Y. Pustules of the fingers: acrodermatitis continua. CMAJ 2016; 188:1105.
- Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. J Am Acad Dermatol 2000; 42:217.
- Hengge UR, Bardeli V. Images in clinical medicine. Green nails. N Engl J Med 2009; 360:1125.
- de Berker DA, Richert B, Duhard E, et al. Retronychia: proximal ingrowing of the nail plate. J Am Acad Dermatol 2008; 58:978.
- Lee HE, Wong WR, Lee MC, Hong HS. Acute paronychia heralding the exacerbation of pemphigus vulgaris. Int J Clin Pract 2004; 58:1174.
- Serratos BD, Rashid RM. Nail disease in pemphigus vulgaris. Dermatol Online J 2009; 15:2.
- Tosti A, André M, Murrell DF. Nail involvement in autoimmune bullous disorders. Dermatol Clin 2011; 29:511.
- Shaw J, Body R. Best evidence topic report. Incision and drainage preferable to oral antibiotics in acute paronychial nail infection? Emerg Med J 2005; 22:813.
- Wollina U. Acute paronychia: comparative treatment with topical antibiotic alone or in combination with corticosteroid. J Eur Acad Dermatol Venereol 2001; 15:82.
- Pierrart J, Delgrande D, Mamane W, et al. Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients. Hand Surg Rehabil 2016; 35:40.
- Tosti R, Ilyas AM. Empiric antibiotics for acute infections of the hand. J Hand Surg Am 2010; 35:125.
- Ogunlusi JD, Oginni LM, Ogunlusi OO. DAREJD simple technique of draining acute paronychia. Tech Hand Up Extrem Surg 2005; 9:120.
- 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.
- Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001; 63:1113.
- Jack C, El Helou T. Non-healing ulcerative paronychia. Lancet 2017; 389:1740.
- Giacomel J, Lallas A, Zalaudek I, Argenziano G. Periungual Bowen disease mimicking chronic paronychia and diagnosed by dermoscopy. J Am Acad Dermatol 2014; 71:e65.
- Lobato-Berezo A, Fernandez-Valencia-Kettunen CK, Burgos-Lazaro F, et al. Ungual squamous cell carcinoma mimicking a chronic paronychia: clinical, pathological and radiological correlation. Dermatol Online J 2015; 21.
- Lee CC, Wu YH. Paronychia-like digital metastases of osteosarcoma. Int J Dermatol 2017; 56:104.
- Ko JH, Young A, Wang KH. Paronychia-like digital cutaneous metastasis. Br J Dermatol 2014; 171:663.
- Chiheb S, El Machbouh L, Marnissi F. Paronychia-like cutaneous leishmaniasis. Dermatol Online J 2015; 21.
- Chaabane H, Turki H. Images in clinical medicine. Cutaneous leishmaniasis with a paronychia-like lesion. N Engl J Med 2014; 371:1736.
- 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.
- Relhan V, Goel K, Bansal S, Garg VK. Management of chronic paronychia. Indian J Dermatol 2014; 59:15.
- Grover C, Bansal S, Nanda S, et al. En bloc excision of proximal nail fold for treatment of chronic paronychia. Dermatol Surg 2006; 32:393.
- Baran R, Bureau H. Surgical treatment of recalcitrant chronic paronychias of the fingers. J Dermatol Surg Oncol 1981; 7:106.
- Ferreira Vieira d'Almeida L, Papaiordanou F, Araújo Machado E, et al. Chronic paronychia treatment: Square flap technique. J Am Acad Dermatol 2016; 75:398.
- Pabari A, Iyer S, Khoo CT. Swiss roll technique for treatment of paronychia. Tech Hand Up Extrem Surg 2011; 15:75.
- ACUTE PARONYCHIA
- Clinical presentation
- Differential diagnosis
- - Paronychia without abscess
- - Paronychia with abscess
- - Toenail paronychia
- CHRONIC PARONYCHIA
- Clinical presentation
- Differential diagnosis
- - General measures
- - First-line therapy
- - Refractory chronic paronychia
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS