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A paronychia is an infection or abscess of the tissues around the base and along the sides of the nail plate. It is the most common infection in the hand.1 A paronychia can be located on the fingers or the toes. It occurs in all age groups. It can cause significant pain and discomfort leading to a visit to the Emergency Department.

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A paronychia initially presents with redness, swelling, and tenderness along the edges of the nail plate. This can progress to an abscess that requires drainage. An infection that extends to the overlying proximal cuticle is termed an eponychia. In this chapter, we will discuss different treatments that vary with the extent of the infection.

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The dorsal aspect of the distal digit consists of the nail plate, the nail bed (matrix), and the perionychium (Figure 90-1). The nail bed is situated beneath the nail plate and is responsible for growth of the nail. The perionychium consists of the soft tissue surrounding the nail plate (eponychium and lateral nail folds).

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Figure 90-1
Graphic Jump Location

The distal finger illustrating a paronychia and the surface anatomy.

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A paronychia is usually the result of frequent trauma, aggressive manicures, hangnails, or nail biting.2 A disruption of the seal between the nail plate and nail fold allows bacteria to enter, leading to pus formation in the eponychial space (Figure 90-1). It begins as a swelling and erythema in the dorsolateral corner of the nail fold that can progress to an abscess. The most common organism to cause a paronychia is Staphylococcus aureus.3 In children, paronychia are often caused by anaerobes secondary to finger sucking or nail biting.4 Gram-negative organisms should be considered in immunocompromised hosts. Chronic paronychia are usually caused by Candida albicans.5

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An early paronychia with signs of cellulitis may be treated nonsurgically with frequent warm soaks, immobilization, elevation, oral antibiotics, and follow-up in 24 hours.2,6 A progression of the infection results in fluctuance and the formation of an abscess. The presence of an abscess, fluctuance, or pus beneath the nail plate requires an incision and drainage procedure.

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A herpetic whitlow is a herpes simplex virus infection of the distal phalanx that can be confused with an early paronychia or felon. The presence of multiple clear vesicles that coalesce suggests a herpetic whitlow. The herpetic whitlow is a nonsurgical and self-limited infection. Treatment consists of a dry dressing to the affected finger in order to prevent autoinoculation and transmission of the infection, oral antiviral agents, and analgesics. Incision and drainage is not recommended, will prolong the recovery, and lead to secondary bacterial infection.7 A chronic paronychia should be referred to a Hand Surgeon or Dermatologist for treatment.

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  • Povidone iodine
  • Sterile gloves
  • # 11 scalpel ...

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