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Paronychia Clinical Presentation

  • Author: Elizabeth M Billingsley, MD; Chief Editor: William D James, MD  more...
 
Updated: Jun 06, 2016
 

History

The patient's history is crucial in determining the possibility of systemic conditions and risk factors that may predispose an individual to paronychia.[13, 17, 18, 19, 20, 21] These may include the following:

  • Diabetes mellitus [22]
  • Obesity
  • Hyperhidrosis
  • Immunologic defects
  • Polyendocrinopathy
  • Drug-induced immunosuppression
  • Retroviral use - Indinavir and lamivudine, in particular, are thought to be associated with an increased incidence of paronychia formation [23, 24]

Patients may give a history of the following[9, 25] :

  • Nail biting
  • Finger sucking
  • Trivial finger trauma
  • Finger exposure to chemical irritants
  • Use of acrylic nails or nail glue
  • Sculpted nails
  • Frequent hand immersion in water

Also query patients about the duration of symptoms and a history of nail infections and previous treatment.

Because paronychia has been known to initiate from malignant lesions, any history of prior malignancy or a pigmented, irregular appearance of surrounding tissue should result in appropriate suspicion and referral for biopsy.

Painless swelling or severe swelling that radiates requires an expanded differential diagnosis.[26] Painless swelling lateral to the nail plate in a patient with osteoarthritis should prompt investigation for a mucous cyst.

Acute paronychia

The patient is usually otherwise healthy but complains of pain, tenderness, and swelling in one of the lateral folds of the nail.

Chronic paronychia

Generally, patients report symptoms lasting 6 weeks or longer. Inflammation, pain, and swelling may occur episodically, often after an exposure to water or a moist environment.

Chronic and recurrent paronychial infections should be scrutinized to rule out malignancy or fungal infection.[27, 28, 29]

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Physical Examination

Acute paronychia

Physical findings in acute paronychia include the following:

  • The affected area often appears erythematous and swollen
  • In more advanced cases, pus may collect under the skin of the lateral fold
  • If untreated, the infection can extend into the eponychium, in which case it is called eponychia
  • Further extension of the infection can lead to the involvement of both lateral folds as it tracks under the nail sulcus; this progression is called a runaround infection

In severe cases, the infection may track proximally under the skin of the finger and volarly to produce a concomitant felon. The fulminant purulence of the nail bed may generate enough pressure to lift the nail off the nail bed.

Chronic paronychia

Physical findings in chronic paronychia include the following:

  • Swollen, erythematous, and tender nail folds without fluctuance are characteristic of chronic paronychia
  • Eventually, the nail plates become thickened and discolored, with pronounced transverse ridges
  • The cuticles and nail folds may separate from the nail plate, forming a space for the invasion of various microorganisms

Additional considerations

Other signs to look for in a physical examination include the following:

  • Look for signs of a herpetic whitlow, such as vesicles on an erythematous base
  • Green coloration of the nail may suggest Pseudomonas species infection
  • Hypertrophy of the nail plate may be a clue to fungal infection
  • Constant severe pain with nail plate elevation, bluish discoloration of the nail plate, and blurring of the lunula suggest the presence of a glomus tumor.

The digital pressure test can be used to detect the presence of an abscess. Pressure is applied to the palmar surface of the distal finger; if an abscess is present, the area of the abscess will blanch with palmar pressure.[30]

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Contributor Information and Disclosures
Author

Elizabeth M Billingsley, MD Professor of Dermatology, Pennsylvania State University College of Medicine; Director, Mohs Micrographic Surgery, Penn State Hershey Medical Center

Elizabeth M Billingsley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, Association of Professors of Dermatology, Council for Nail Disorders, Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Allison T Vidimos, MD, RPh Chair, Department of Dermatology, Vice Chair, Dermatology and Plastic Surgery Institute, Staff Physician, Department of Dermatology and Dermatologic Surgery and Cutaneous Oncology, Cleveland Clinic; Professor of Dermatology, Department of Medicine, Case Western Reserve University School of Medicine

Allison T Vidimos, MD, RPh is a member of the following medical societies: American Academy of Dermatology, Association of Professors of Dermatology, International Transplant and Skin Cancer Collaborative, American College of Mohs Surgery, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery

Disclosure: Partner received grant/research funds from Genentech for none.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Yelena Bogdan Stony Brook University Health Sciences Center School of Medicine (SUNY)

Disclosure: Nothing to disclose.

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Noah Elise Gudel, DO Resident in Internal Medicine, University of Tennessee Medical Center at Knoxville

Disclosure: Nothing to disclose.

Micelle J Haydel, MD Associate Clinical Professor of Medicine, Residency Director, Section of Emergency Medicine, Louisiana State University Health Science Center

Micelle J Haydel, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, Sigma Theta Tau International, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Mark F Hendrickson, MD Chief, Section of Hand Surgery, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

Steve Lee, MD Physician in Plastic, Reconstructive, and Hand Surgery, Plastic Surgery, PLLC

Steve Lee, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Mohamad Marouf, MD Consulting Staff, Department of Emergency Medicine, University Hospitals Health System, Richmond Heights Medical Center

Disclosure: Nothing to disclose.

Heather Murphy-Lavoie, MD, FAAEM Assistant Professor, Assistant Residency Director, Emergency Medicine Residency, Associate Program Director, Hyperbaric Medicine Fellowship, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine in New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine

Heather Murphy-Lavoie, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Jerome FX Naradzay, MD, FACEP Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina

Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Julia R Nunley, MD Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center

Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina; Professor Emeritus of Dermatology, Columbia University

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Dermatological Association, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeter (Jay) Pritchard Taylor III, MD Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Classic presentation of paronychia, with erythema and pus surrounding the nail bed. In this case, the paronychia was due to infection after a hangnail was removed.
In this case of paronychia, no pus or fluctuance is involved in the nail bed itself.
Typical appearance of paronychia.
Depicted are the nail fold (A), dorsal roof (B), ventral floor (C), nail wall (D), perionychium (E), lunula (F), nail bed (G), germinal matrix (H), sterile matrix (I), nail plate (J), hyponychium (K), distal groove (L), fascial septa (M), fat pad (N), distal interphalangeal joint (O), and extensor tendon insertion (P).
Simple acute paronychia can be drained by elevating the eponychial fold from the nail with a small blunt instrument such as a metal probe or elevator.
Paronychia incision and drainage.
Paronychial erythema and edema with associated pustule. This suggests a bacterial etiology.
Paronychia, side view.
After simple drainage, there is purulent return.
Wound opened with a small incision using a number-11 blade scalpel.
The wound can be explored with a blunt probe, clamps, or the blunt end of a cotton swab.
Ensure that all loculations are broken up and that as much pus as possible is evacuated.
Prior to packing or dressing the wound, irrigate the wound with normal saline under pressure, using a splash guard, eye protection, or both.
The wound can be covered with antibiotic ointment or petroleum jelly to prevent bandage adhesion.
 
 
 
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