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Indian Journal of Dermatology

Medknow Publications
Management of Chronic Paronychia
Vineet Relhan, Khushbu Goel, !!!", and Vi#ay Kumar Garg
$dditional article information
Abstract
%hronic &aronychia is an inflammatory disorder of the nail folds of a toe or finger
&resenting as redness, tenderness, and swelling! It is recalcitrant dermatoses seen
commonly in housewi'es and housemaids! It is a multifactorial inflammatory reaction
of the &ro(imal nail fold to irritants and allergens! Re&eated bouts of inflammation
lead to fibrosis of &ro(imal nail fold with &oor generation of cuticle, which in turn
e(&oses the nail further to irritants and allergens! )hus, general &re'enti'e measures
form cornerstone of the thera&y! )hough &re'iously anti*fungals were the mainstay of
thera&y, to&ical steroid creams ha'e been found to be more effecti'e in the treatment
of chronic &aronychia! In recalcitrant cases, surgical treatment may be resorted to,
which includes en bloc e(cision of the &ro(imal nail fold or an e&onychial
marsu&iali+ation, with or without nail &late remo'al! ,ewer thera&ies and surgical
modalities are being em&loyed in the management of chronic &aronychia! In this
o'er'iew, we re'iew recent e&idemiological studies, &resent current thinking on the
&atho&hysiology leading to chronic &aronychia, discuss the challenges chronic
&aronychia &resents, and recommend a commonsense a&&roach to management!
Keywords: Chronic paronychia, en bloc excision of nail fold, hand dermatitis
Introduction
What was known?
%hronic &aronychia was considered a form of fungal infection affecting the nail folds
with anti*fungals being the mainstay of treatment! -urgical management like
e&onychial marsu&iali+ation and en bloc e(cision of nail fold was done in recalcitrant
cases without nail &late remo'al!
%hronic &aronychia is an inflammatory recalcitrant disorder affecting the nail folds! It
can be defined as an inflammation lasting for more than . weeks and in'ol'ing one
or more of the three nail folds /one &ro(imal and two lateral0!1" )his re'iew aims to
throw a light on the current conce&ts in etio&athogenesis of chronic &aronychia and
brings in detail the &ast and &resent management strategies with s&ecial focus on
newer thera&ies!
Structure of nail
)he nail is a com&le( unit com&osed of fi'e ma#or modified cutaneous structures2
)he nail matri(, nail &late, nail bed, cuticle /e&onychium0, and nail folds!3" )he nail
bed, which consists of 3 &ortions, is &rimarily in'ol'ed in the &roduction, migration,
and maintenance of the nail! )he &ro(imal &ortion, called the germinal matri(,
contains acti'e cells that are res&onsible for generating new nail! Damage to the
germinal matri( results in malformed nails! )he distal &ortion, the sterile matri(, adds
thickness, bulk, and strength to the nail! )he nail arises from a mild &ro(imal
de&ression called the &ro(imal nail fold! )he nail di'ides the nail fold into 3
com&onents2 )he dorsal roof and the 'entral floor, both of which contain germinal
matrices! %uticle is an outgrowth of the &ro(imal nail fold /P,40 and is situated
between the skin of the digit and the nail &late, fusing these structures together! )his
configuration &ro'ides a water&roof seal from e(ternal irritants, allergens, and
&athogens! In chronic &aronychia, this seal is broken5 the irritants enter the s&ace
thus created!
Clinical features
)he &atient &resents with com&laint of redness, tenderness, swelling, fluid under the
nail folds, and thick discolored nail 4igure 1"! Mor&hologically, it is characteri+ed by
induration and rounding off of the &aronychium, recurring e&isodes of acute
e&onychial inflammation and drainage! ,ail &late may show thickening and
longitudinal groo'ing! 6nychomadesis, trans'erse striation, &itting, hy&ertro&hy can
be &resent and are &robably due to inflammation of nail matri(!7" ,ail &late may
&resent a green discoloration of its lateral margins due to Pseudomonas
aeruginosacoloni+ation!
4igure 1
$ case of &aronychia with rounding off of &eronychium and thick, discoloured nails
Pathogenesis
Re&eated bouts of inflammation, &ersistent edema, induration, and fibrosis of
&ro(imal and lateral nail folds causes the nail folds to round u& and retract, thereby
e(&osing the nail groo'es further! )his loss of an effecti'e seal leads to a &ersistent
retention of moisture, infecti'e organisms and irritants within the groo'es, in turn
e(acerbating the acute flare*u&s! )his 'icious cycle goes on, com&romising the
ability to regenerate the cuticle! )he inflamed and fibrosed P,4 &rogressi'ely loses
its 'ascular su&&ly 4igure 3"! )his is res&onsible for failure of medical treatment
measures! )o&ical drugs fail to &enetrate chronically inflamed skin, and systemic
drugs cannot be deli'ered to areas of decreased 'ascular su&&ly!8"
4igure 3
Pathogenesis of chronic &aronychia
Etiology
It has a com&le( &athogenesis and is caused by multifactorial damage to the cuticle,
thereby e(&osing the nail fold and the nail groo'e!9" Pre'iously, it was belie'ed that
chronic &aronychia is caused by Candida!." :owe'er, recent data re'eals that it is a
form of hand dermatitis caused by en'ironmental e(&osure! Candida is often
isolated5 howe'er, in many cases, Candida disa&&ears when the &hysiologic barrier
is restored!;" :ence, the recent 'iew holds that chronic &aronychia is not a mycotic
disease but an ec+ematous condition with a multifactorial etiology! 4or this reason,
to&ical and systemic steroids may be used successfully, whereas systemic anti*
fungals are of little 'alue! )osti et al!;" disco'ered that to&ical steroids are more
effecti'e than systemic anti*fungals in the treatment of chronic &aronychia!
$lthough Candida was fre<uently isolated from the P,4 of their &atients with chronic
&aronychia, Candida eradication was not associated with clinical cure in most
&atients!
In a study conducted by Rigo&oulos D et al!,=" tacrolimus 1> ointment and
betamethasone 1;*'alerate cream was found to be more effecti'e in &atients of
chronic &aronychia than #ust emollient a&&lication, confirming allergens and irritants
ha'e indeed an im&ortant contribution to the &athogenesis of chronic &aronychia!
%hronic &aronychia commonly afflicts house and office cleaners, laundry workers,
food handlers, cooks, dishwashers, bartenders, chefs, nurses, swimmers, diabetes,
and &atients on :IV*$R)! :y&ersensiti'ity to foodstuff is res&onsible for an increased
incidence in food handlers!?"
)here are many rare causes of chronic &aronychia, which should always be ke&t in
mind and some of which include the following2
Infections /@acterial, mycobacterial, or 'iral0
RaynaudAs disease
Metastatic cancer, subungual melanoma, s<uamous cell carcinoma! @enign
and malignant neo&lasms should always be e(cluded when chronic &aronychia does
not res&ond to con'entional treatment
Pa&ulos<uamous disorders like &soriasis, 'esicobullous disorders*&em&higus
Drug to(icity from medications such as retinoids, e&idermal growth factor*
rece&tor inhibitors /cetu(imab0, and &rotease inhibitors! Indina'ir* induces retinoid*
like effects and remains the most fre<uent cause of chronic &aronychia in &atients
with :IV disease! Retinoids also induce chronic &aronychia! )he mechanism can be
*nail fragility and minor trauma by small nail fragments!1B" Paronychia has also
been re&orted in &atients taking cetu(imab /Crbitu(0, an anti*e&idermal growth factor*
rece&tor /CG4R0 antibody used in the treatment of solid tumors!11"
Differential diagnosis
)he differential diagnosis of chronic &aronychia includes s<uamous cell carcinoma of
the nail, malignant melanoma, metastases from malignant tumors! )he clinician
should consider the &ossibility of the carcinoma when a chronic inflammatory
&rocess is unres&onsi'e to treatment! $ny sus&icion for the aforementioned entities
should &rom&t bio&sy!
Treatment of chronic paronychia
Various treatment o&tions for management of chronic &aronychia ha'e been enlisted
in )able 1!
)able 1
)reatment o&tions for management of chronic &aronychia
General measures
)hese measures hel& in &re'ention as well as work synergistically with other acti'e
measures in im&ro'ing the healing time and decreasing further recurrences! )he
basic aim is a'oidance of aggra'ating factors and minimi+ing further in#ury by
reducing the mani&ulation of the nail! )he former may be achie'ed by a'oiding
e(&osure to moist en'ironments and contact irritants such as soa&s and detergents!
)he affected area should be ke&t dry, and moisturi+ers should be a&&lied after
washing hands! Rubber glo'es should be used, &referably with inner cotton glo'e or
cotton liners while &erforming any work with &robable e(&osure to irritants!13"
4urther in#ury may be minimi+ed by kee&ing the nails short and a'oiding any
mani&ulation of the nail, such as manicuring, finger sucking, or self attem&t to incise
and drain the lesion! )he footwear should be &ro&erly chosen to a'oid unnecessary
damage to the nail! )he &atients with diabetes should maintain a strict glycemic
control!13"
Medical management of chronic paronychia
Initially, organisms such as Candida and intestinal bacteria were causally related to
this condition!17,18" )hus, anti*fungals &layed an im&ortant role in the management
of chronic &aronychia in the &ast, and se'eral studies using to&ical or systemic anti*
fungals ha'e re&orted encouraging results! Dong et al!19" com&ared the thera&eutic
effect of ketocona+ole tablets and econa+ole lotion in the treatment of chronic
&aronychia and found them com&arable in efficacy! :owe'er, they continued to
isolateCandida s&ecies in cured &atients, thus suggesting that total elimination of
organisms is not necessary for com&lete reco'ery! Eikewise, bacteria including
micrococci, di&htheroids, and gram*negati'e organisms were reco'ered from nail*
folds throughout the treatment &eriod &ro'ing the multifactorial origin of the condition!
Daniel et al! assessed the efficacy of ciclo&iro( B!;;> to&ical sus&ension in
combination with a strict irritant*a'oidance regimen in &atients with sim&le chronic
&aronychia andFor onycholysis and showed e(cellent thera&eutic outcomes!1."
)hough anti*fungals were the mainstay of thera&y in the &ast, some in'estigators
ha'e suggested that the thera&eutic &otential of anti*fungals in chronic &aronychia
might be attributed e<ually to the anti*fungal and to the anti*inflammatory &ro&erties
of these agents!1" C'en in studies showing a good thera&eutic effect, some of the
&atients re&orted unsuccessful anti*fungal thera&y in the &ast!1;" )hus, the
accumulating e'idence indicates that chronic &aronychia is an ec+ematous condition
as discussed abo'e!1=,1?" 4or this reason, to&ical and systemic steroids ha'e
become the first line of thera&y, whereas to&ical and systemic anti*fungals are of little
'alue now, being used only when there is an associated fungal infection!
)osti et al!;" conducted a randomi+ed, double*blind study to com&are the efficacy of
systemic anti*fungals /itracona+ole 3BB mg daily or terbinafine 39B mg daily0 'ersus
a to&ical corticosteroid /methyl&rednisolone ace&onate cream B!1>, 9 mg daily0 in
the treatment of 89 adult &atients with chronic &aronychia o'er 7 weeks! )he follow*
u& &eriod was of . weeks! )he statistical analysis showed a significant difference
between the number of nails im&ro'ed or cured by methyl&rednisolone ace&onate
/81 out of 8=0 and that of nails im&ro'ed or cured with terbinafine /7B out of 9;0 or
itracona+ole /3? out of .80! Presence of Candida was not strictly linked to disease
acti'ity, andCandida eradication was associated with clinical cure in only 3 of the 1=
&atients who carried Candida!
)acrolimus has been used successfully in treatment of ato&ic and allergic contact
dermatitis! @ased on this fact and that irritants and allergens &lay a &i'otal role of in
the de'elo&ment of chronic &aronychia, Rigo&oulos et al!=" conducted a
randomi+ed, unblinded, com&arati'e study to com&are the efficacy of tacrolimus
ointment B!1> 's! betamethasone 1;*'alerate B!1> 's! emollient a&&lication for 7
weeks in the treatment of 89 &atients with chronic &aronychia! @oth betamethasone
and tacrolimus grou&s &resented statistically significantly greater cure or
im&ro'ement rates when com&ared with the emollient grou&, and tacrolimus
ointment a&&eared to be a more efficacious than betamethasone 1;*'alerate or
&lacebo for the treatment of chronic &aronychia! Possible effect of tacrolimus was
e(&lained by its role in the elicitation &hase of allergic contact dermatitis through
inhibition of dendritic cell migration into the draining lym&h node3B" and su&&ression
of both irritant and contact &atch test reactions!31" In addition, the ointment
formulation of the tacrolimus might offer increased benefit on the im&aired barrier
function of the inflammatory &erionychium!
Surgical management of chronic paronychia
-urgical management is only indicated in recalcitrant cases of chronic &aronychia,
which does not res&ond to medical management and &ro&er use of general
measures! -urgical treatment is re<uired in such cases to remo'e the chronically
inflamed tissue, which aids in effecti'e &enetration of to&ical as well as oral
medications and regeneration of the cuticle!
Various surgical techni<ues with modifications ha'e been described in literature!
Keyser et al!33" in 1?;9 suggested sim&le e&onychial marsu&iali+ation as the
treatment of chronic &aronychia! In this techni<ue, after anesthesia and tourni<uet
control, a crescent*sha&ed incision &arallel and &ro(imal to the distal edge of
e&onychium and e(tending from the radial to ulnar borders was made 4igure 7"! )he
width of the crescent was 7 mm from &ro(imal to distal edge! $ll affected tissue
within the boundaries of the crescent and e(tending down to, but not including, the
germinal matri( is e(cised and &acked with gau+e &ieces! )hus, this &rocedure
e(teriori+es the infected and obstructed nail matri( and allows its drainage!
C&itheliali+ation of the e(cised defect occurs o'er the ne(t 3*7 weeks!
4igure 7
C&onychial marsu&ili+ation in a case of chronic &aronychia
@ednar et al!8" in 1??1 treated ;F3= fingers with marsu&iali+ation alone and found
recurrences in two of these &atients who had nail &late irregularities! )he 1. &atients
with nail irregularities were treated with marsu&iali+ation &lus nail remo'al, and there
were no recurrences with statistically significant difference! )he two &atients treated
with marsu&ili+ation alone who showed recurrence were retreated with
marsu&iali+ation and nail remo'al and both im&ro'ed significantly! )hus, they further
confirmed that e&onychial marsu&iali+ation is an effecti'e means of treating chronic
&aronychia and suggested that nail remo'al should also be done when concurrent
nail irregularities are seen as e&onychial marsu&iali+ation only drains the dorsal
surface of the dorsal roof of germinal matri(, whereas nail remo'al more thoroughly
debrides the entire nail fold by &ermitting drainage of the 'olar &ortion of the dorsal
roof as well as the 'entral floor!
C&onychial marsu&ili+ation &reser'es the 'entral surface of the P,4, which forms the
dorsal roof or surface of the nail &late, thus the authors claimed that it &roduces a
cosmetically more acce&table result as com&ared to en bloc e(cision of P,4
/com&lete remo'al of the dorsal roof including the e&onychium0, since it &re'ents any
subse<uent roughness or lack of shininess o'er the nail &late surface!
@aran et al!37" -uggested en bloc e(cision of &ro(imal nail fold as a treatment
o&tion for chronic &aronychia based on their obser'ation that sites of bio&sies from
&ro(imal nail fold in cases of collagen disorders healed une'entfully without scarring
or distortion in about three weeks! In this &rocedure, they e(cised a crescent*sha&ed
&iece of full thickness skin, 9*. mm wide at greatest diameter that e(tends from one
lateral nail fold to the o&&osite one and includes the entire &ro(imal nail fold 4igure
8"! %om&lete healing and restoration occurred in three months! )hey &ostulated that
this method was sim&ler, curati'e, and cosmetically and functionally more
satisfactory than e&onychial marsu&iali+ation!
4igure 8
Cn bloc e(cision of the &ro(imal nail fold in a case of chronic &ronychia
Gro'er et al!38" treated 7B &atients of chronic &aronychia with nail &late irregularities
by en bloc e(cision of P,4 with or without nail &late remo'al! 6f these, ;B> of
&atients were cured in grou&, in which en bloc e(cision with nail a'ulsion was
&erformed, whereas only 81> were cured in grou& where en bloc e(cision without
nail a'ulsion was &erformed5 howe'er, the difference was not significant statistically!
)hus, they concluded that though en bloc e(cision of the P,4 is a useful method in
recalcitrant &aronychia, simultaneous nail a'ulsion im&ro'es the surgical outcome!
)he authors also claimed that a fibrosed, a'ascular distal e&onychium would not
contribute effecti'ely towards a normal nail &late surface or &roduce a new cuticle as
&ostulated by su&&orters of e&onychial marsu&ili+ation, and thus &reser'ing the
e&onychium does not offer any added ad'antage! Moreo'er, all these &atients of en
bloc e(cision of P,4 showed an effecti'e regeneration of e&onychium and cuticle
with normal attachment to nail &late and no loss of &ost*o& shininess!
Recently, Pabari et al!39" described -wiss roll techni<ue for chronic and se'ere
acute &aronychia with run around infection in'ol'ing both nail folds! In this techni<ue,
the nail fold is ele'ated by making an incision on either side using a no! 19 scal&el
blade with the scal&el ti& &ointed away from the nail bed to &re'ent iatrogenic
deformity of the nail 4igure 9"! )he ele'ated nail fold is reflected &ro(imally o'er a
non*adherent dressing 4igure ." that is rolled u& like a -wiss roll and secured to the
skin with 3 anchoring non*absorbable sutures! )he e(&osure of the nail bed allows
drainage of any residual infection! )he finger is subse<uently dressed with a sim&le
finger dressing! If the wound is clean at 8= hours, the anchoring sutures are
remo'ed, and the nail fold is allowed to fall back to its original &osition and heal by
secondary intention! In chronic &aronychia, the fold may be ke&t o&en for u& to ;
days to allow ade<uate drainage! )his techni<ue has the ad'antage of retaining the
nail &late and allowing ra&id healing without creating a defect in the skin!
4igure 9
-wiss roll techni<ue2 Incision made on either side of nail fold for nail fold ele'ation
/ada&ted from Pabari $, Iyer -, Khoo %)! -wiss roll techni<ue for treatment of
&aronychia! )ech :and -urg 3B115192;9*;0
4igure .
-wiss roll techni<ue2 Cle'ated nail fold is reflected &ro(imally o'er a non*adherent
dressing /ada&ted from Pabari $, Iyer -, Khoo %)! -wiss roll techni<ue for treatment
of &aronychia! )ech :and -urg 3B115192;9*;0
Prognosis
%hronic &aronychia res&onds slowly to treatment and may take se'eral weeks or
months, but this should not be a deterrent to thera&y! If the &atient is not treated,
s&oradic &ainful e&isodes of acute inflammation may be e(&erienced as a result of
continuous &enetration of 'arious &athogens!
Conclusion
)hus, chronic &aronychia should no longer be considered a mycotic disease but an
ec+ematous condition with multifactorial etiology! Pre'enti'e measures should
always form the main &art of thera&y! )o&ical steroids ha'e a ma#or role to &lay in
thera&y and are more effecti'e than systemic anti*fungals /le'el of e'idence @0!
)acrolimus has recently shown to ha'e &romising results! -urgical thera&y should be
resorted to in recalcitrant cases, and simultaneous nail remo'al augments the results
in most cases!
What is new?
%hronic &aronychia has a multifactorial etiology and is &rimarily a form of hand
dermatitis and not fungal infection! -teroids ha'e a definite edge o'er anti*fungals in
the management of chronic &aronychia! )acrolimus has recently shown to ha'e
&romising results! )he surgical methods used for recalcitrant cases gi'e better
results when the nail &late is also remo'ed simultaneously! $ new surgical techni<ue
namely -wiss roll techni<ue has been described, which has the ad'antage of
retaining the nail &late and allowing ra&id healing without creating a defect in the
skin!
Article information
Indian J Dermatol !"#$ Jan%&eb' ()*#+, #(-!"
doi, #"$#"./""#)%(#($#!.$0!
PMCID, PMC.00$)!#
1ineet 2elhan3 4hushbu Goel3 Shi5ha 6ansal3
#
and 1i7ay 4umar Garg
!
From the Department of Dermatology, VMMC and Safdurjung Hospital, Delhi, India
#
Specialist, VMMC and Safdurjung Hospital, Delhi, India
!
Director Professor and Head, MAMC, VMMC and Safdurjung Hospital, Delhi, India
Address for correspondence: Dr Vineet !elhan, "#$F, Sector$%, SFS Flats, &asola Vihar, 'e( Delhi $
)#, India *$mail+ ,ineetrelhan-at-gmailcom
2ecei8ed December !"#!' Accepted &ebruary !"#.
Copyright , 9 Indian Journal of Dermatology
This is an open%access article distributed under the terms of the Creati8e Commons Attribution%
:oncommercial%Share Ali5e ." ;nported3 <hich permits unrestricted use3 distribution3 and
reproduction in any medium3 pro8ided the original <or5 is properly cited
Articles from Indian Journal of Dermatology are pro8ided here courtesy of Medknow Publications
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