Chronic Paronychia

See Also

Definition

More than 6 weeks of nail fold inflammation

Pathophysiology

Cuticle separates from nail plate resulting in a space between nail fold and nail plate
Resulting pocket accumulates irritants, as well as fungi and Bacteria

Mechanisms

Exposures
1. Exposure to water with irritants or Alcohol
2. Repeated exposure to moist environment
Occupation
1. Baker
2. Bartender
3. Dishwasher
4. Housekeeper
5. Homemaker
6. Swimmer
Comorbid condition
1. Diabetes Mellitus
2. Human Immunodeficiency Virus (HIV Infection)
3. Immunocompromised condition
4. Medications
  1. Retinoids
  2. Protease Inhibitors (4% of users, esp. Indinavir)
  3. Anti-Epidermal Growth Factor Receptor Antibody (17% of users, esp. Cetuximab )
  4. Chemotherapy (35% of users)
Superinfections of chronic irritation
1. Candida albicans (95%)
  1. Typically only a colonizer and not related to Chronic Paronychia pathogenesis
2. Atypical Mycobacteria
3. Gram Negative Rods
4. Gram Negative Cocci

Differential Diagnosis

Signs

Early characteristics
1. Swollen and tender nail folds
2. Less redness than in Acute Paronychia
Later characteristics
1. Nail plates thick and discolored
2. Nail plate with deep transverse ridges (Beau Lines)
3. Loss of cuticle
Distribution
1. Typically involves multiple digits
2. Consider alternative diagnosis when only a single digit is involved (e.g. Squamous Cell Skin Cancer)
Duration: 6 weeks or longer

Management

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
First Line management: Anti-inflammatory medications
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 [PubMed]
2. Calcineuron inhibitors
  1. Tacrolimus (Protopic) 0.1%
Other management: Antimicrobials
1. Antimicrobials are no longer recommended for Chronic Paronychia
  1. Although candida colonizes most Chronic Paronychia, it is not causative
  2. Antiinflammatory agents (e.g. Corticosteroids) alone are the mainstay of Paronychia management
2. May consider treating as Acute Paronychia
  1. See Acute Paronychia management for Antibiotics and other measures (e.g. soaks)
  2. Consider pseudomonal Paronychia coverage
    1. Especially for greenish discoloration in a chronically moist environment
    2. Treat with topical neomycin ointment
3. Older Antifungal regimens (no longer recommended)
  1. Topical Antifungal Medications alone or combined with Corticosteroid (for up to 1 month)
    1. Nystatin cream or
    2. Clotrimazole cream or
    3. Terbinafine (Lamisil) in refractory cases
  2. Systemic Antifungals in refractory cases (again, not recommended)
    1. Fluconazole 100 mg orally once daily for 7-14 days or
    2. Itraconazole 200 mg orally twice daily for 7 days
Other Management: Medication causes of Chronic Paronychia and their management
1. Chemotherapy-induced Chronic Paronychia
  1. Povidone-Iodine 1% in dimethyl sulfoxide applied twice daily until cleared
  2. Capriotti (2015) Clin Cosmet Investing Dermatol 8:489-91 [PubMed]
2. Protease Inhibitors Indinavir (Antiretroviral agent)
  1. Consider switching to other Antiretroviral
  2. Garcia-Silva (2002) Drug Saf 25:993-1003 [PubMed]
3. Cetuximab (epidermal growth factor agent)
  1. Associated Paronychia is treated with Doxycycline
  2. Shu (2006) Br J Dermatol 154: 191-2 [PubMed]
Other Management: Vitamin Supplementation
1. Zinc supplementation
  1. Zinc Deficiency has been associated with Chronic Paronychia and other
  2. Zinc 20 mg orally daily
  3. Iorizzo (2015) Dermatol Clin 33(2): 175-83 [PubMed]
Refractory cases: Surgery
1. Swiss Roll Technique
  1. https://www.youtube.com/watch?v=5BC_xwSGVHs
  2. Pabari (2011) Tech Hand Up Extrem Surg 15(2):75-7 [PubMed]
2. Proximal nail fold and nail plate excision
3. Marsupialization of Eponychium

References