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Chronic Paronychia Review DOI: 10.6003/jtad.18121r1 Chronic Paronychia Burhan Engin,* MD, Muazzez Çiğdem Oba, MD, Zekayi Kutlubay, MD, Server Serdaroğlu, MD Address: * Department of Dermatology and Venereology Istanbul University, Cerrahpaşa Medical Faculty E-mail: [email protected] Corresponding Author: Dr.Burhan Engin, Department of Dermatology and Venereology Istanbul University, Cerrahpaşa Medical Faculty İstanbul, Turkey Published: J Turk Acad Dermatol 2018; 12 (1): 18121r1. This article is available from: http://www.jtad.org/2018/1/jtad18121r1.pdf Keywords: Chronic paronychia, clinical features, inflammation, management, nail folds Abstract Background: Chronic paronychia is a common inflammatory disorder characterized by erythema, edema, and tenderness involving the nail folds for at least 6 weeks. The condition is related to repeated exposure to moist environments, irritants and allergens. Secondary colonization by fungal and bacterial pathogens is thought to exacerbate the persistent inflammation. Preventive measures are crucial to help healing and reduce recurrence rates. Medical management consists mainly of anti-inflammatory treatments. In recalcitrant cases not responding to medical treatments and preventive measures various surgical modalities may be used. In this article, we aimed to review the etiopathogenesis, clinical features and management of chronic paronychia. Introduction acute paronychia may also lead to chronic paronychia [3]. Chronic paronychia is an inflammatory disor- der affecting the nail fold. The condition is de- Etiology is multifactorial including excessive fined as inflammation lasting at least six moisture, contact irritants, contact allergy, weeks involving one or more of the three nail food hypersensitivity, trauma and candida folds [1]. It is a common occupational di- hypersensitivity. Contact sensitization to al- sease, particularly prevalent in housemaids, lergens shown by positive patch test reactions barte nders, barbers, dishwashers, cooks, is high among patients with chronic paronyc- food handlers, swimmers and nurses [2]. Pre- hia. There is also a higher incidence of prick ventive measures are crucial to help healing test reactions to Candida allergen proving and reduce recurrence rates. Medical mana- that hypersensitivity to Candida is more im- gement consists mainly of anti-inflammatory portant than Candida infection in the deve- treatments. In recalcitrant cases not respon- lopment of chronic paronychia [4]. ding to medical treatments and preventive In most cases, this eczematous condition m measures various surgical modalities may be ay be secondarily colonized with bacterial used. and/or fungal agents [5]. Previously Candida Etiology infection was believed to be the cause of the disease as this yeast was isolated from 40 to Chronic paronychia is a contact dermatitis 95% of cases. However restoration of physio- caused by environmental exposure to irri- logic barrier but not the Candida eradication tants and allergens. Improper treatment of is associated with good clinical outcomes as Page 1 of 4 (page number not for citation purposes) J Turk Acad Dermatol 2018; 12 (1): 18121r1. http://www.jtad.org/2018/1/jtad18121r1.pdf Figure 1. Erythema, edema of the nail folds are seen along with some nail plate changes Candida is only a secondary colonizer [6]. cuticle is observed. Episodic exacerbations Apart from Candida, atypical mycobacteria, may occur. Nail plate changes are commonly gram-negative rods and gram-negative cocci observed in patients with chronic paronychia. have been implicated in chronic paronychia Thickening and discoloration of the nail plate, [7]. onychomadesis, Beau’s lines and pitting can Retinoids (eg, etretinate), epidermal growth be present [6,8,11]. factor receptor inhibitors (eg, cetuximab, ge- A clinical staging system has been proposed fitinib) and protease inhibitors (eg, indinavir, by Daniel et al in order to have a standardized lamivudine) may cause chronic paronychia [8,9,10]. Conditions such as diabetes melli- description of chronic paronychia. According tus and immunosuppression also predispose to this classification stage I presents with patients to development of chronic paronyc- mild redness and swelling of the nail folds hia [7]. with disruption of the cuticle. In stage II di- sease redness and swelling of the nail f Pathogenesis olds is pronounced. Stage III disease is cha- Persistent inflammation involving the nail racterized with loss of cuticle, some discom- fold disrupts normal barrier function of the fort and some nail plate changes. In stage IV, nail unit by causing the separation of the nail symptoms of tenderness and pain are obser- fold from the nail plate. This separation al- ved along with extensive nail plate changes. lows the entry of allergens, irritants and mi Stage V represents acute exacerba-tion of croorganisms thus perpetuating the inflam- chronic paronychia [12]. matory process. This vicious cycle leads to the loss of the cuticle and fibrosis of the pro- Differential Diagnosis ximal nail fold [6]. The differential diagnosis of chronic paronyc- Clinical Features hia includes squamous cell carcinoma of the Diagnosis of chronic paronychia is based on nail, subungal melanoma and digital metas- physical examination of the nail unit. The tases of malignant tumors [13, 14, 15, 16]. condition mainly affects adult women and is An underlying malignancy should be suspec- more commonly seen in the hands than in ted in cases unresponsive to conventional tre- the feet. Chronic paronychia is characterized atments [6]. Papulosquamous diseases such by the erythema, edema and tenderness of as psoriasis and other diseases affecting the the nail folds (Figure 1). Induration and ro- digits may involve nail folds and mimic chro- unding off of paronychium along with loss of nic paronychia [8]. Page 2 of 4 (page number not for citation purposes) J Turk Acad Dermatol 2018; 12 (1): 18121r1. http://www.jtad.org/2018/1/jtad18121r1.pdf Management Daniel et al reported excellent therapeutic outcomes with the combined regimen of cic- Management of chronic paronychia consists lopirox application twice daily for 6-12 weeks of general preventive measures, medical ma- and contact-irritant avoidance [20]. nagement and surgical management. Medical and surgical treatment options for chronic Tacrolimus 0,1% ointment may be used for paronychia are summarized in (Table 1). the treatment of chronic paronychia. A ran- domized study assigned 45 adults with chr General Preventive Measures onic paronychia to treatment with 0.1% tac- The preventive measures are aimed at avoi- rolimus ointment or 0,1% betamethasone 17- ding any activity that impairs the normal bar- valerate cream or emollient application for 3 rier function of the nail fold. Patients should weeks. Both tacrolimus and betamethasone avoid exposure to moist environments and to led to significantly greater improvement com- contact irritants such as soaps and deter- pared with emollient treatment and tacroli- gents. Regular application of moisturizers mus appeared to be more efficacious than and the use of rubber gloves with cotton li- bethametasone [21]. ners are other important preventive measures In a recent pilot study, the efficacy of neo- minimizing irritant contact. Patients should dymium-doped yttrium aluminium garnet be instructed to keep the nails short and to (Nd:YAG) laser for the treatment of chronic avoid any activity that may injure the nail paronychia was assessed. Two to five monthly unit such as manicuring and finger sucking Nd-YAG laser sessions were applied to 8 fe- [6]. male patients with long-standing paronychia. Medical Management Fluences of 70 to 80 J/cm2 and 2.5 mm spot size handpiece were utilized with 0.7 ms First-line medical treatment for this conditio pulse duration. Seven of the patients showed n is topical corticosteroids [6]. Antifungal improvement of the erythema and swelling agents were the mainstay of therapy in the and six of them had also improvement in nail past [17]. A randomized controlled study in- plate abnormalities. The beneficial effects of volving 45 patients with chronic paronychia Nd-YAG laser on chronic paronychia may be compared topical methylprednisolone acepo- attributed to elevation of vascular permeabi- nate with oral terbinafine and itraconazole lity and thus improving vascular microcircu- treatments. The results showed a significant lation [22]. difference between the number of nails im- proved or cured by methylprednisolone ace- Zinc deficiency is associated with nail plate ponate than that of nails improved or cured abnormalities and chronic paronychia. 20 mg with systemic antifungal agents [18]. Syste- of oral supplemental zinc per day is a helpful mic antifungals are usually not recommen- treatment adjunct [23]. ded for the treatment of chronic paronychia. Surgical Management However, in one study fluconazole 50mg/day was reported to be effective [19]. Surgical approaches must be tried only in re- calcitrant cases not responding to medical Monthly injections of triamcinolone acetonide management and strict application of preven- suspension at a concentration of 2.5mg/ml tive measures [6]. can be considered in refractory cases. Short courses of systemic steroids (methylpredni- Surgical treatment options for chron sone 20 mg/day) may be used in severe cases ic paronychia consist of eponychial marsu- to obtain rapid relief of inflammation [19]. pialization with or without nail plate removal, Table 1. Medical and Surgical Treatment Options for Chronic Paronychia
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