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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
%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
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
4igure 1
$ case of &aronychia with rounding off of &eronychium and thick, discoloured nails
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
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!
$lthough Candida was fre<uently isolated from the P,4 of their &atients with chronic
&aronychia, Candida eradication was not associated with clinical cure in most
In a study conducted by Rigo&oulos D et al!,=" tacrolimus 1> ointment and
betamethasone 1;*'alerate cream was found to be more effecti'e in &atients of
chronic &aronychia than #ust emollient a&&lication, confirming allergens and irritants
ha'e indeed an im&ortant contribution to the &athogenesis of chronic &aronychia!
%hronic &aronychia commonly afflicts house and office cleaners, laundry workers,
food handlers, cooks, dishwashers, bartenders, chefs, nurses, swimmers, diabetes,
and &atients on :IV*$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
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
%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!
)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
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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