Paronychia in Emergency Medicine Clinical Presentation

  • Author: Heather Murphy-Lavoie, MD, FAAEM; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Oct 20, 2010
 

History

The patient is usually otherwise healthy but complains of acute onset of pain and swelling around the nail.

  • Patients may give a history of nail biting, finger sucking, trivial finger trauma, finger exposure to chemical irritants, acrylic nails or nail glue, sculpted nails, or frequent hand immersion in water.[2, 5]
  • Query patients about the duration of symptoms, history of nail infections and previous treatment, and exposure to chemicals or water. Several medications are thought to affect the nail matrix, resulting in an increase in associated infections.[6, 7, 8, 9, 10, 11, 12]
  • It is important to identify risk factors for a more complicated course such as diabetes mellitus,[13] immunocompromise, history of steroids, and retroviral use. Indinavir and lamivudine, in particular, are thought to be associated with an increased incidence of paronychia formation.[6, 14] Painless swelling or severe swelling that radiates requires an expanded differential diagnosis.[15]
  • Pain and swelling surrounding the nail are the most common complaints.
  • Chronic and recurrent paronychial infections should be scrutinized to rule out malignancy or fungal infection.[16, 17, 18]
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Physical

  • Erythema
  • Edema
  • Tenderness along the lateral nail fold
  • Fluctuance
  • 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, and, if an abscess is present, the area of the abscess will blanch with palmar pressure.[19]
  • Infection may be isolated to the lateral nail fold; however, the finger and hand should be examined closely to rule out any extension of the infection such as a runaround abscess, abscess extending under the nail plate, felon, or tendonitis.
  • Examine closely for any tissue irregularity that may be a clue to malignancy.
  • Look for signs of herpetic whitlow infection 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.
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Causes

  • Acute paronychia is most commonly caused by Staphylococcus aureus or Streptococcus species.
  • A mixed bacterial infection is common, particularly in patients with diabetes.[20]
  • If recurrent or chronic, the infection has an increased likelihood of being mycotic, primarily Candida albicans.[21]
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Contributor Information and Disclosures
Author

Heather Murphy-Lavoie, MD, FAAEM  Assistant Professor, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine, 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.

Coauthor(s)

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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine 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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; 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.

References

  1. Brook I. Aerobic and anaerobic microbiology of paronychia. Ann Emerg Med. Sep 1990;19(9):994-6. [Medline].

  2. Chronic paronychia: what you should know. Am Fam Physician. Feb 1 2008;77(3):347-8. [Medline].

  3. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. Mar 15 2001;63(6):1113-6. [Medline].

  4. Canales FL, Newmeyer WL 3rd, Kilgore ES Jr. The treatment of felons and paronychias. Hand Clin. Nov 1989;5(4):515-23. [Medline].

  5. Dahdah MJ, Scher RK. Nail diseases related to nail cosmetics. Dermatol Clin. Apr 2006;24(2):233-9, vii. [Medline].

  6. Colson AE, Sax PE, Keller MJ, et al. Paronychia in association with indinavir treatment. Clin Infect Dis. Jan 2001;32(1):140-3. [Medline].

  7. Hijjawi JB, Dennison DG. Acute felon as a complication of systemic Paclitaxel therapy: case report and review of the literature. Hand. Sep 2007;2(3):101-3. [Medline].

  8. Eames T, Grabein B, Kroth J, Wollenberg A. Microbiological analysis of epidermal growth factor receptor inhibitor therapy-associated paronychia. J Eur Acad Dermatol Venereol. Aug 2010;24(8):958-60. [Medline].

  9. Tomková H, Kohoutek M, Zábojníková M, Pospísková M, Ostrízková L, Gharibyar M. Cetuximab-induced cutaneous toxicity. J Eur Acad Dermatol Venereol. Jun 2010;24(6):692-6. [Medline].

  10. Osio A, Mateus C, Soria JC, et al. Cutaneous side-effects in patients on long-term treatment with epidermal growth factor receptor inhibitors. Br J Dermatol. Sep 2009;161(3):515-21. [Medline].

  11. Gilbar P, Hain A, Peereboom VM. Nail toxicity induced by cancer chemotherapy. J Oncol Pharm Pract. Sep 2009;15(3):143-55. [Medline].

  12. Rigopoulos D, Gregoriou S, Belyayeva Y, Larios G, Gkouvi A, Katsambas A. Acute paronychia caused by lapatinib therapy. Clin Exp Dermatol. Jan 2009;34(1):94-5. [Medline].

  13. Kapellen TM, Galler A, Kiess W. Higher frequency of paronychia (nail bed infections) in pediatric and adolescent patients with type 1 diabetes mellitus than in non-diabetic peers. J Pediatr Endocrinol Metab. Jun 2003;16(5):751-8. [Medline].

  14. Tosti A, Piraccini BM, D'Antuono A, Marzaduri S, Bettoli V. Paronychia associated with antiretroviral therapy. Br J Dermatol. Jun 1999;140(6):1165-8. [Medline].

  15. Yip KM, Lam SL, Shee BW, Shun CT, Yang RS. Subungual squamous cell carcinoma: report of 2 cases. J Formos Med Assoc. Aug 2000;99(8):646-9. [Medline].

  16. Daniel CR 3rd. Paronychia. Dermatol Clin. Jul 1985;3(3):461-4. [Medline].

  17. Jules KT, Bonar PL. Nail infections. Clin Podiatr Med Surg. Apr 1989;6(2):403-16. [Medline].

  18. Muniz AE, Evans T. Chronic paronychia, osteomyelitis, and paravertebral abscess in a child with blastomycosis. J Emerg Med. Oct 2000;19(3):245-8. [Medline].

  19. Turkmen A, Warner RM, Page RE. Digital pressure test for paronychia. Br J Plast Surg. Jan 2004;57(1):93-4. [Medline].

  20. Riesbeck K. Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological diagnosis is crucial. J Clin Microbiol. Oct 2003;41(10):4901-3. [Medline]. [Full Text].

  21. Daniel CR 3rd, Daniel MP, Daniel J, Sullivan S, Bell FE. Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen. Cutis. Jan 2004;73(1):81-5. [Medline].

  22. Fung V, Sainsbury DC, Seukeran DC, Allison KP. Squamous cell carcinoma of the finger masquerading as paronychia. J Plast Reconstr Aesthet Surg. Feb 2010;63(2):e191-2. [Medline].

  23. Engineer L, Norton LA, Ahmed AR. Nail involvement in pemphigus vulgaris. J Am Acad Dermatol. Sep 2000;43(3):529-35. [Medline].

  24. Patsatsi A, Sotiriou E, Devliotou-Panagiotidou D, Sotiriadis D. Pemphigus vulgaris affecting 19 nails. Clin Exp Dermatol. Mar 2009;34(2):202-5. [Medline].

  25. Jebson PJ. Infections of the fingertip. Paronychias and felons. Hand Clin. Nov 1998;14(4):547-55, viii. [Medline].

 
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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.
 
 
 
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