Chronic Paronychia

Aka: Chronic Paronychia

1. See Also
   1. Acute Paronychia
   2. Hand Infection
2. Definition
   1. More than 6 weeks of nail fold inflammation
3. Pathophysiology
   1. Cuticle separates from nail plate resulting in a space between nail fold and nail plate
   2. Resulting pocket accumulates irritants, as well as fungi and bacteria
4. Mechanisms
   1. Exposures
      1. Exposure to water with irritants or Alcohol
      2. Repeated exposure to moist environment
   2. Occupation
      1. Baker
      2. Bartender
      3. Dishwasher
      4. Housekeeper
      5. Homemaker
      6. Swimmer
   3. Comorbid condition
      1. Diabetes Mellitus
      2. Human Immunodeficiency Virus (HIV Infection)
      3. Immunocompromised condition
      4. Medications
         1. Retinoids
         2. Indinavir (Antiretroviral agent)
         3. Cetuximab
5. Etiology
   1. Candida albicans (95%)
      1. May only be colonizer and not related to Chronic Paronychia pathogenesis
   2. Atypical Mycobacteria
   3. Gram Negative Rods
   4. Gram Negative Cocci
6. Differential Diagnosis
   1. Metastatic cancer
   2. Subungual Melanoma
   3. Squamous Cell Carcinoma
7. Signs and Symptoms
   1. Early characteristics
      1. Swollen and tender nail folds
      2. Less redness than in Acute Paronychia
   2. Later characteristics
      1. Nail plates thick and discolored
      2. Nail plate with transverse ridges
   3. Duration: 6 weeks or longer
8. Management
   1. Avoid precipitating factors
      1. Avoid irritants (use hypoallergenic products, dye and perfume free)
      2. Avoid prolonged water exposure
      3. Avoid nail trauma
         1. Avoid manicures
         2. Avoid finger sucking
         3. Keep nails short
      4. Use gloves to prevent frequent emersion of finger tips
         1. Avoid vinyl gloves (or use cotton gloves underneath)
      5. Apply Skin Lubricants after hand washing
   2. First Line management: Topical Corticosteroids with or without Topical Antifungals
      1. Topical Corticosteroids (preferred)
         1. Medium to high potency agents for up to 3 weeks
         2. Systemic Corticosteroids could be considered in severe, diffuse cases
         3. Tosti (2002) J Am Acad Dermatol 47:73-6
      2. Topical Antifungal Medications (for up to 1 month)
         1. Nystatin cream or
         2. Clotrimazole cream or
         3. Terbinafine (Lamisil) in refractory cases
      3. Consider combination agent
         1. Nystatin with Triamcinolone
         2. Clotrimazole with Betamethasone (Lotrisone)
            1. One of few cases where this potent combination is appropriate
         3. However, Corticosteroids appear to be effective alone
      4. Consider pseudomonal Paronychia coverage
         1. Especially for greenish discoloration in a chronically moist environment
         2. Treat with topical neomycin ointment
   3. Second Line management: Treat as Acute Paronychia
      1. See Acute Paronychia management for antibiotics and other measures (e.g. soaks)
   4. Third Line medications: Systemic Antifungals
      1. Fluconazole 100 mg orally once daily for 7-14 days or
      2. Itraconazole 200 mg orally twice daily for 7 days
   5. Refractory cases: Surgery
      1. Proximal nail fold and nail plate excision or
      2. Marsupialization of Eponychium
   6. Special circumstances
      1. Indinavir (Antiretroviral agent)
         1. Consider switching to other Antiretroviral
         2. Garcia-Silva (2002) Drug Saf 25:993-1003
      2. Cetuximab (epidermal growth factor agent)
         1. Associated Paronychia is treated with Doxycycline
         2. Shu (2006) Br J Dermatol 154: 191-2
9. References
   1. Brook (1990) Ann Emerg Med 19:994-6
   2. Hochman (1995) Int J Dermatol 34:385-6
   3. Rigopoulos (2008) Am Fam Physician 77:339-48
   4. Rockwell (2001) Am Fam Physician 63(6): 113-6
   5. Jebson (1998) Hand Clin 14:547-55