A 37-year-old patient presents complaining of severe pain and swelling around the nail of his right fourth finger. His condition has been present several days and is worsening.
On physical exam the proximal nail fold of the patient’s fourth right finger is tender to palpation. There is fluctuance and a small yellowish abscess.
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This patient was diagnosed with acute paronychia. Paronychia is a common infection of the hand affecting the perionychium, or epidermis bordering the nail. Infection develops when the seal of the nail fold along the nail plate is disrupted, allowing pathogens to establish a localized superficial infection or abscess. Noninfectious causes of paronychia include contact irritants, excessive water contact or drug side effect.
Acute paronychia commonly results from minor trauma such as nail biting, cuticle removing or penetrating trauma. The most common infectious organism is Staphylococcus aureus. Patients with acute paronychia present with localized pain and tenderness in the perionychium with associated erythema and inflammation. Surgical drainage is necessary when abscess or fluctuance is present. Anti-staphylococcal antibiotics may be indicated.
Chronic paronychia refers to inflammation that has been present for more than six weeks and involves one or more of the proximal or lateral nail folds. Chronic paronychia clinically resembles acute paronychia, presenting with swollen, red nail folds. The nail plates become thickened and discolored, and the cuticles and nail folds may separate from the nail plate.
Chronic paronychia is usually nonsuppurative and can be more difficult to treat. Risk factors include occupational exposure to moist environments, as well as diabetes and immunosuppression. The most common pathogen associated with chronic paronychia is Candida albicans.
Retinoids and protease inhibitors may also cause chronic paronychia. Treatment involves avoiding predisposing factors and a combination of topical steroids and antifungal agents. Refractory chronic paronychia may be treated by surgical excision of the involved fold.
Onychorrhexis, or brittle nail, most commonly occurs in the fingernails and may present with longitudinal ridging, transverse splitting, fissuring of the distal nail plate or horizontal lamellar separation. Brittle nails may be idiopathic or may occur due to environmental and occupational factors. Onychorrhexis may also be secondary to systemic or dermatologic disease, nutritional deficiencies and drugs. Therapeutic approaches to brittle nail are generally targeted to the inciting cause.
Onycholysis describes the detachment of the nail plate from its nail bed, usually beginning at the distal portion of the nail bed and progressing proximally. Detachment can be seen clinically because the presence of air renders the onycholytic part of the nail opaque. Because the process is usually gradual, onycholysis is usually painless.
Onycholysis may be a symptom of systemic disease or the result of drug reaction or infection. Several dermatologic diseases can manifest with detached nail plates including psoriasis, porphyria cutanea tarda, pemphigus vulgaris and Darier’s disease.
Diya Banerjee, BA, is a medical student at Baylor College of Medicine.
Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine also in Houston.
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