Pyogenic paronychia: causes, symptoms, diagnosis, and treatment

Pyrogenic paronychia is an acute or chronic suppurative infection of the skin around the nail and is characterized by redness, swelling, suppuration or incrustation, accompanied by significant pain.


Causes

Acute paronychia is caused mostly by staphylococcal infection, and often secondary to local trauma, laceration, and bites. Chronic paronychia often results from macerated skin folds easily separated from the nail wall and infected by pyogenic cocci, pseudomonas aeruginosa, candidas, and Proteus vulgaris.


Signs and Symptoms

The duration of disease <6 weeks is acute paronychia, and the duration of disease >6 weeks is chronic paronychia.

Acute paronychia

Mild redness, swelling, pain, and tenderness occur in the nail groove initially, sometimes, spontaneously subsiding, sometimes suppurating, and can evolve into paronychia or subungual abscess, with intensified pain, with subungual yellow pus accumulations. The affected nail can be separated from the base.

Chronic paronychia

Chronic paronychia develops slowly and persists for long time. Mild redness, swelling, pain, and exfoliation of the nail cuticle are present. A small amount of pus is discharged out of the nail groove, and the edge of the nail and the nail groove darken, gradually forming nodular or fungiform raised inflammatory granulation tissue, with pus, with hemorrhage when scratches, Partial nail is damaged, onychodystrophy is present, longitudinal ridge or transverse groove on the nail are visible, and pus is beneath the nail. In severe cases, nail separation and onychomadesis are present.


Diagnosis

On the basis of typical clinical presentations, diagnosis is not difficult.


Treatment

Acute paronychia

Oral antibiotics, such as cotrimoxazole, cephalexin, amoxicillin/clavulanic acid, or clindamycin, can often cover common positive bacteria such as staphylococcus aureus and streptococci. If MRSA is suspected, oral trimethoprim is required. If oral flora infection is suspected, broad spectrum antibiotics such as amoxicillin and clavulanate potassium tablets should be used to cover the anaerobes.

If with obvious abscess, incision and drainage is necessary.

If with subungual abscess, the nail plate should be partially or completely excised.

Chronic paronychia

The first step in the treatment of chronic paronychia is to avoid stimulation and excessive moisture.

Topical hormonal medications, such as 0.1% betamethasone ointment and 0.1% tacrolimus ointment, should be a first-line treatment for chronic paronychia.

For patients with recurrent chronic paronychia, a systemic antifungal treatment regimen may be considered prior to surgical intervention.

Eponychial marsupialization, excision of proximal nail fold, or Swiss roll technique can be used for the treatment of chronic paronychia.