Paronychia Clinical Presentation

Updated: Oct 22, 2018
  • Author: Elizabeth M Billingsley, MD; Chief Editor: William D James, MD  more...
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Presentation

History

The patient's history is crucial in determining the possibility of systemic conditions and risk factors that may predispose an individual to paronychia. [15, 20, 21, 22, 23, 24] These may include the following:

  • Diabetes mellitus [25]

  • 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 [26, 27]

Patients may give a history of the following [9, 28] :

  • 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. [29] 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. [30, 31, 32]

Next:

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. [33]

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