A 35-year-old woman presents to the dermatology clinic with inflammation of her fingernails that first appeared 5 months ago and recently worsened. She reports wearing acrylic nails for the last year, removing them just before the clinic visit. On examination, the patient has erythema and swelling of the lateral nail folds and hyperpigmentation of the proximal nail folds of all fingers on her right hand. Examination also reveals nail dystrophy, onycholysis, and an absence of cuticles. She has not tried any treatments for this condition.
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Chronic paronychia is an inflammatory condition of the nail folds lasting longer than 6 weeks.1 Descriptions of paronychia in the medical literature date back to 1891.2 Chronic paronychia primarily results from environmental exposures, irritants, and allergens.1,3,4
More common in women, chronic paronychia typically affects multiple digits, especially the second and third digits of the dominant hand.4,5 The condition commonly occurs in patients aged 40 to 49 years, with a mean age at diagnosis of 43 years.6,7
Etiology and Risk Factors
Chronic paronychia results from inflammation of the perionychium of the nail. It is usually caused by damage to the cuticle that disrupts the barrier between the nail plate and the skin, allowing invasion of fungus or bacteria. Generally, any activity that subjects the nail bed to trauma increases the risk for paronychia. For example, frequent manicures and wearing artificial nails, nail biting, hangnail manipulation, and ingrown nails are risk factors for chronic paronychia.1
Chronic paronychia also is associated with continuous exposure to environmental irritants and, thus, is thought to be a form of hand dermatitis.3,5 Chefs, nurses, swimmers, house cleaners, dishwashers, and barbers are more likely to develop chronic paronychia due to repeated exposure to chemicals, acids, or alkalis.1,3,5,6 People who handle food may develop chronic paronychia due to food hypersensitivity reactions.3
Other populations predisposed to chronic paronychia include patients with diabetes, patients on antiretroviral therapy for HIV, and patients who are immunosuppressed.3,5 Less common causes of chronic paronychia include Raynaud disease, papulosquamous disorders, cancers, and drug toxicity.3
Candida albicans commonly is implicated in the etiology of chronic paronychia and is found in 40% to 95% of fungal cultures of patients with chronic paronychia.5 However, research suggests that topical steroids are more effective than systemic antifungal therapy at treating chronic paronychia.3,5,8 It is thought that Candida albicans infects the nail bed secondary to an existing inflammatory condition.3,5
Diagnosis of Chronic Paronychia
Clinically, chronic paronychia presents with cuticle damage, pain, and swelling and erythema of the nail fold. The condition often affects multiple digits.1,5 Nails often are thick and discolored. Damage to the nail matrix can lead to nail plate abnormalities, such as pitting, onychomadesis, longitudinal ridging, and Beau lines, whereas damage to the nail bed can lead to onycholysis. Lateral margins of the nail plate may even become green, suggesting secondary infection with Pseudomonas aeruginosa.3
The differential diagnosis for chronic paronychia includes several cancers that should be considered when the symptoms affect a single digit, the condition does not respond to treatment, or patients have a history of cancer.1,3,5 The following cancers may cause nail damage: malignant melanoma, squamous cell carcinoma, Kaposi sarcoma, bronchogenic carcinoma, leukemia cutis, subungual keratoacanthoma, myeloma-associated systemic amyloidosis, and digital papillary adenocarcinoma.5
Other conditions that may mimic chronic paronychia include herpetic whitlow, psoriasis, eczema, granuloma annulare, Reiter syndrome, dermatomyositis, pyogenic granuloma, hematoma from pulse oximetry, and, rarely, pemphigus vulgaris and food hypersensitivity.1
Treatment of Chronic Paronychia
Chronic paronychia is diagnosed based on clinical findings and patient history, which generally reveal exposure to irritants or other risk factors.1,5 Clinical history also may reveal episodic worsening of symptoms of paronychia after exposure to moisture.5 If the practitioner suspects malignancy, a nail biopsy may be needed.5 When infection is suspected, a culture for bacteria, fungi, and atypical mycobacteria may be indicated.5 Acute paronychia differs from chronic paronychia because it persists for less than 6 weeks, typically affects a single digit, and results in greater swelling and erythema.1,5
Chronic paronychia can be managed surgically or nonsurgically.1,3,5 It is essential to counsel the patient about avoidance of environmental triggers, including irritants, allergens, chemicals, nail manipulation, and moisture.3,5 Patients also may be advised, when appropriate, to use rubber gloves, keep nails short, and wear comfortable footwear to avoid toenail damage.3 Patients with diabetes should maintain proper glycemic control.3
Topical corticosteroids are used as first-line treatment and topical antifungals may be added; oral antifungals are not indicated.3,5 Tacrolimus ointment (1%) also can be used as an alternative to topical steroid therapy.3,9 Antibiotics (topical or systemic) may be necessary in the presence of secondary infections.3 Overall, response to therapy is slow, and chronic paronychia can take months to resolve, but patients should be advised to continue to avoid triggers and persist with treatment.3
In patients whose condition is unresponsive to nonsurgical measures, surgery is indicated to remove the inflamed tissue or a portion of the eponychium.3,5
The patient in this case was counseled to avoid acrylic nails and was prescribed clobetasol ointment twice daily for 2 weeks and ketoconazole cream twice daily for 4 weeks. This treatment helped improve the inflammation around her nails, although the nail dystrophy still was present at her 3-month follow-up visit.
Dina Zamil, BS, is a medical student at Baylor College of Medicine, Tara L. Braun, MD, is a resident in the Department of Dermatology at Baylor College of Medicine, and Christopher Rizk, MD, is a dermatologist affiliated with Baylor College of Medicine in Houston, Texas.
1. Leggit JC. Acute and chronic paronychia. Am Fam Physician. 2017;96(1):44-51.
2. Diseases of the fingers : B-paronychia. Hospital (Lond 1886). 1891;10(254):226.
3. Relhan V, Goel K, Bansal S, Garg VK. Management of chronic paronychia. Indian J Dermatol. 2014;59(1):15-20. doi:10.4103/0019-5154.123482.
4. Atış G, Göktay F, Altan Ferhatoğlu Z, et al. A proposal for a new severity index for the evaluation of chronic paronychia. Skin Appendage Disord. 2018;5(1):32-37. doi:10.1159/000489024.
5. Shafritz AB, Coppage JM. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014;22(3):165-174. doi:10.5435/JAAOS-22-03-165.
6. Bahunuthula RK, Thappa DM, Kumari R, Singh R, Munisamy M, Parija SC. Evaluation of role of Candida in patients with chronic paronychia. Indian J Dermatol Venereol Leprol. 2015;81(5):485-490. doi:10.4103/0378-6323.158635.
7. Chow E, Goh CL. Epidemiology of chronic paronychia in a skin hospital in Singapore. Int J Dermatol. 1991;30(11):795-798. doi:10.1111/j.1365-4362.1991.tb04789.x.
8. Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002;47(1):73-76. doi:10.1067/mjd.2002.122191
9. Rigopoulos D, Gregoriou S, Belyayeva E, Larios G, Kontochristopoulos G, Katsambas A. Efficacy and safety of tacrolimus ointment 0.1% vs. betamethasone 17-valerate 0.1% in the treatment of chronic paronychia: an unblinded randomized study. Br J Dermatol. 2009;160(4):858-860. doi:10.1111/j.1365-2133.2008.08988.x.