CHRONIC PARONYCHIA

By Gary M. White, MD


chronic paronychia

Note the chronic, eczematous skin changes around the nail.


Chronic paronychia (CP) may be defined as inflammation of the skin about the nail lasting longer than 6 weeks. There are several possible underlying mechanisms:

  1. A chronic eczematous condition from either irritant or allergic contact dermatitis. Repeated water contact and an atopic background are predisposing factors. Typical occupations are bartenders, cooks, dishwashers and homemakers.
  2. Chronic infection, e.g. from Candida or Staphylococcus. Woman who constantly push back the cuticle are at risk.
  3. A combination of the two. For example, an acute infection may lead to chronically inflamed skin in predisposed people, e.g. atopics, masseuse, dishwasher, bartender, etc. Or chronically inflamed skin may become secondarily infected.

Clinical

The skin about one or more nails is inflamed. If chronic, dystrophy of the nails often occurs. This is particularly true if the inflammation is proximal to the nail over the nail matrix. Grooves, pits, and roughness may develop. The cuticle is lost and there may be hypertrophy of the proximal and lateral nail folds.

Differential Diagnosis

Contact urticaria or allergic contact dermatitis to foods or spices may induce a chronic paronychia. Patch testing may be helpful here. Some collagen vascular diseases cause inflammation of the cuticular area.

Treatment

Treatment for both infection and inflammation are often in order. A course of an oral anti staphylococcal antibiotic or antifungal agent, e.g. fluconazole may be given, often in conjunction with a potent topical steroid. Culture of any pus or liquid should be performed. Avoiding water contact and frequent use of emollients are key. Ointments are better than creams which are better than lotions. No manicures. No manipulating the cuticle. Avoid prolonged water contact with the hands, e.g., use gloves when doing the dishes. If painful fissure occurs, cyanoacrylate (super glue, e.g., Krazy Glue) may be recommended (see hand dermatitis handout--fissures section). One of my patients derived great benefit from applying liquid bandage every morning to the cuticle area (in order to restore the seal). The patient should be educated that fixing the skin changes allows the nails to normalize over time.

If the job is the main problem, taking a vacation or break may be necessary. Patients should make sure to try to heal on days off by avoiding water, etc. One of my patients who was a masseuse would flare every time she used flax seed oil during the massage. Wearing gloves fixed the problem. Tacrolimus ointment was shown to be helpful in one study.

A hand dermatitis handout is available.

Square Flap Technique

The square flap technique is a surgical procedure that removes fibrotic tissue without complete excision of the nail fold [JAAD 2016;75;398]. According to the report, the procedure has a high cure rate and an excellent cosmetic outcome.

Additional Pictures

Note the mild nail dystrophy which is common in chronic paronychia.
chronic paronychia along with mild nail dystrophy

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