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Acute and Chronic Paronychia of the Hand

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Acute and Chronic Paronychia of the Hand Review Article Acute and Chronic Paronychia of the Hand Abstract Adam B. Shafritz, MD Acute and chronic infections and inflammation adjacent to the Jeff M. Coppage, MD fingernail, or paronychia, are common. Paronychia typically develops following a breakdown in the barrier between the nail plate and the adjacent nail fold and is often caused by bacterial or fungal pathogens; however, noninfectious etiologies, such as chemical irritants, excessive moisture, systemic conditions, and medications, can cause nail changes. Abscesses associated with acute infections may spontaneously decompress or may require drainage and local wound care along with a short course of appropriate antibiotics. Chronic infections have a multifactorial etiology and can lead to nail changes, including thickening, ridging, and discoloration. Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia. nflammation of the tissue immedi- the flexor and extensor tendons.3 Iately surrounding the nail, known Fibrous septa located within the pulp as paronychia, is commonly caused by of the finger stabilize the vascular fi- acute or chronic infection. Paronychia brofatty tissue and bridge the dermis can be acute (,6weeksduration)or to the periosteum of the distal pha- chronic ($6 weeks duration) and lanx.4 Thenailbed,whichhasacon- typically develops following a break- voluted attachment to the periosteum down in the barrier between the nail of the distal phalanx, resists traumatic plate and the adjacent nail fold that is avulsion. In humans, the fingernail often caused by bacterial or fungal protects the fingertip and enhances its pathogens. However, noninfectious dexterity and sensation by exerting From the Department of Orthopaedics etiologies such as chemical irritants, counterpressure for the volar pulp and Rehabilitation, University of Vermont College of Medicine, excessive moisture, systemic con- during touch and facilitating skilled Burlington, VT. ditions, and medications also can hand function, such as the ability cause paronychia. Management op- to pick up and manipulate small Neither of the following authors nor 5 any immediate family member has tions include activity modification objects. received anything of value from or has along with medical and/or surgical The nailbed comprises germinal and stock or stock options held in intervention based on the etiology, sterile matrices, with the germinal a commercial company or institution related directly or indirectly to the duration, extent of paronychial matrix located on the palmar aspect of subject of this article: Dr. Shafritz and involvement, and the associated risk the nail fold and terminating at the Dr. Coppage. factors present.1,2 distal extent of the lunula. This matrix J Am Acad Orthop Surg 2014;22: is more vascular than the remainder of 165-174 Anatomy the nail bed and produces nearly all of 4 http://dx.doi.org/10.5435/ the nail via gradient parakeratosis. JAAOS-22-03-165 The tip of the finger is composed of Near the periosteum, germinal matrix osseous tissue, soft tissue, and spe- cells originate as basilar cells. They Copyright 2014 by the American Academy of Orthopaedic Surgeons. cialized tissues that produce and sup- duplicate and are driven dorsally in port the nail distal to the insertions of columns toward the nail. The cells March 2014, Vol 22, No 3 165 Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Acute and Chronic Paronychia of the Hand Figure 1 Hyponychium Nail plate with sterile matrix below Paronychium Lunula Nail bed Insertion of Nail vest Nail fold Nail plate extensor tendon with germinal Sterile matrix Germinal matrix matrix below Eponychium Dorsal floor Nail Ventral fold floor DIP joint Hyponychium A B Illustrations of dorsal (A) and cross-section (B) views of the anatomy of the fingertip and nail bed. DIP = distal interphalangeal flatten and stream distally when they the paronychium.7 The junction where fingertip’s natural barrier to outside meet the resistance of the nail, leading the sterile matrix of the distal nail bed pathogens, resulting in inoculation of to longitudinal nail growth.4 The nail meets the skin of the fingertip is called the perionychium. In three studies with bed and the nail plate are involved in the hyponychium. A keratinous plug a total of 61 patients with paronychia, the continuum of nail production at all with abundant neutrophils and lym- approximately 25% of paronychias stages. phocytes composes the hyponychium, were caused by anaerobic bacteria, The sterile matrix lies distal to the whichservesasabarrierinpreventing 25% by aerobic bacteria, and 50% lunula. Its contribution to nail pro- microbial invasion of the subungual by mixed aerobic and anaerobic bac- duction varies. Cells that originate area.4 The nail fold is an anatomic teria.8-10 The most common aerobic from the sterile matrix enlarge, flatten, transition between the nail bed and the pathogens responsible for acute par- and elongate; large cells eventually paronychium. The eponychium lies at onychia include Staphylococcus break down and are incorporated into the most distal and dorsal portion of aureus, gamma-hemolytic strepto- the nail. In most people, the nail is the nail fold; this is where the nail fold cocci, Eikenella corrodens, group A thicker distally than proximally, pro- attaches to the surface of the nail. At b-hemolytic streptococci, and Klebsi- viding evidence of the contribution of this junction, the nail vest (a thin veil of ella pneumoniae.8 Common anaerobic the sterile matrix to nail production. tissue) is formed. bacteria responsible for paronychia The nail plate is anchored to the include Bacteroides species, gram-pos- underlying linear ridges in the squa- Acute Paronychia itive anaerobic cocci, and Fusobacteria mous epithelium of the sterile matrix.4 species.8 Enterococcus faecalis, Pro- The nail adheres less to the germinal teus species, and Pseudomonas aer- matrix than to the sterile matrix. Etiology and Risk Factors uginosa are other isolated organisms The paronychium is defined as the Most acute paronychias are the result that can cause paronychia.8 In addi- soft tissue lateral to the nail bed, of minor trauma to the nail bed that is tion, nonbacterial pathogens such as whereas the term perionychium refers often related to onychophagia (ie, nail yeast (Candida albicans) and viruses to the paronychium and nail bed6 biting), finger sucking, picking at (eg, herpes simplex) have been iden- (Figure 1). Primate studies suggest that a hangnail, an ingrown nail, man- tified as causative organisms. A spe- after nail removal, the sterile matrix icures, dishwashing, or puncture-type cific trauma or inciting event may contributes little to nail regeneration trauma with or without a retained not be identified in all cases of acute and the nail is primarily reformed by foreign body. Such trauma disrupts the paronychia. 166 Journal of the American Academy of Orthopaedic Surgeons Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Adam B. Shafritz, MD, and Jeff M. Coppage, MD Figure 2 Figure 3 Figure 4 Photograph of a fingertip A, Photograph of a fingertip demonstrating herpetic whitlow. demonstrating an acute paronychia (Reproduced with permission from and its sequelae. The patient Usatine RP, Tinitigan R: Nongenital presented with acute onset of pain and herpes simplex virus. Am Fam swelling. The abscess spontaneously Physician 2010;82[9]:1075-1082.) decompressed under the nail fold and nail plate. B, Photograph of the fingertip obtained 3 weeks later. The aspect of the digit12 (Figure 4). The infection resolved and a new nail is Photograph of a fingertip blisters are typically filled with serous- growing to replace the one present at demonstrating an abscess, which type fluid, but the fluid may be more the time of infection. is evident from the blanched area caused by simple digital pinch opaque and can be easily mistaken for pressure. (Courtesy of Robert purulence. Herpetic whitlow is often Clinical Presentation Strauch, MD, New York, NY.) seen in healthcare professionals (eg, Patients with acute paronychias typ- dental professionals) who are at risk ically present with localized pain, may provide exposure to specific of topical exposure to the virus, but redness, inflammation, and edema of anaerobic bacteria such as Eikenella the condition may also be seen in the paronychium that is typically corrodens or the herpes virus. Expo- persons with a primary herpes sim- 13 limited to a single digit. The timing of sure to animals may result in an plex infection. A definitive diagnosis presentation varies, but is often 2 to increased risk of infection with gram- is made based on Tzanck smear or 5 days after the initial trauma. Fluc- negative organisms such as Pasteurella viral culture results. Incision and tuance of the paronychium may not multocida. drainage are contraindicated. be observed with early presentation. Turkmen etal11 described the use of In addition, to herpetic whitlow, In patients with delayed presentation, a digital pressure test to identify the other conditions such as psoriasis, fluctuance may extend around the presence and extent of paronychial Reiter syndrome, and pemphigus nail, involving the eponychium as abscesses. The test is performed by vulgaris can mimic acute or chronic well as the paronychium on both the applying light pressure to the distal paronychia. Medications such
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