36 year old female presents to the emergency department complaining of a swollen left ring finger having ‘pulled a hangnail’ from the finger 2 days previously. Examination reveals a swollen, erthematous nail fold with visible pus present.
- Paronychia is an inflammatory involvement of the fold of the nail on the radial or ulnar side. It can effect both fingers and toes.
- Pus, erythema and swelling develop between the nail and nail fold causing throbbing pain and discomfort.
- The most common cause is direct or indirect trauma to the cuticle or nail fold.
- The most common organism involved in paronychia is Staph aureus, although Strep pyrogenes, Pseudomonas pyocyanea, and Proteus vulgaris.
- The condition is characterised by rapid onset of erythema, oedema, and discomfort or tenderness of the proximal or lateral nail folds.
Acute Vs Chronic Paronychia
- Acute paronychia result’s from direct or indirect trauma and generally takes between 2-5days for it to occur.
- Chronic paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens.
- Repeat acute paronychial infections can also result in chronic paronychia, or when acute paronychia hasn’t been treated properly.
- Treatment of chronic paronychia involves removing allergens and irritates, organism targeted antibiotic or antifungal’s, application of topical emollients, and good hygiene. Corticosteroids can be used if no response to the above or multiple fingernails are involved.
Be aware of other conditions that can affect fingertips:
• Squamous cell carcinoma
• Malignant melanoma
• Malignant tumors
• Eczema or psoriasis
• Reiter’s syndrome
Management of Paronychia:
- Draining the paronychia involves making a longitudinal incision parallel to the nail edge across the nail fold to release the pus, under a ring block anaesthetic.
- Mop out the cavity made with pledgets of cotton wool.
- Soak the digit then in a saline solution and irrigate away any debris. The dress the digit with an antibacterial or simple dressing.
- There is no evidence that antibiotics are any better than incision and drainage, patient with severe paronychia with tracking cellulitis require admission for intravenous antibiotics.
- Patients not admitted for intravenous antibiotics need to be discharge home on oral antibiotics, encourage to elevate the digit, and should be reviewed in 24-48hours.
- Brown, A. & Cadogan, M. (2006). Hand Infections: Paronychia. Emergency Medicine: Emergency and Acute Medicine: Diagnosis and Management. pp. 328. London: Hodder Arnold [Reference]
- Rigopoulos, D. Larios, G. Gregoriou, S. & Alevizos, A. Acute and Chronic Paronychia. American Family Physician. Am Fam Physician. 2008 Feb 1;77(3):339-46. [Reference]
- Shaw, J. & Body, R. (2005). Best evidence topic report. Incision and drainage preferable to oral antibiotics in acute paronychial nail infection? Emergency Medicine Journal. 22(11), 813-814. [Reference]