Paronychia and ingrown toenail

EBM Guidelines
23.5.2017

Essentials

  • Acute paronychia usually responds well to simple drainage of the abscess without the need for systemic antimicrobials.
  • An ingrown toenail often requires partial nail avulsion.
  • Chronic paronychia is encountered mainly in people whose hands are repeatedly exposed to water.

Aetiology

  • Acute paronychia
    • May manifest itself as a painful abscess at the nail fold, or it may become chronic when the cuticle disappears and the entire nail fold becomes erythematous with or without flaking skin.
    • An acute infection starts from a small cut (e.g. nail biting or a manicure procedure) or an ingrown edge of a nail.
    • The most common causative agent is Staphylococcus aureus.
  • Chronic paronychia (picture «Chronic paronychia»1)
    • The aetiology is multifactorial and cannot be explained by infection alone.
    • It may halt the growth of the nail and the nail plate may become partially detached (pictures «Nail damage caused by paronychia»2 «Nail lesions caused by paronychia»3).
    • Particularly encountered in people involved in wet working conditions. A swab collected from under the nail fold may grow Candida albicans with simultaneous bacterial growth, including S. aureus, pseudomonas or E. coli, the clinical significance of which remains controversial.

Treatment

Acute infection

  • In an acute phase the abscess is drained under local anaesthesia with an incision along the axis of the finger (for example, a scalpel blade no. 11).
  • The debridement of any infected necrotic tissue is carried out with a suitable instrument and the cavity is rinsed with, for example, physiological saline.
  • The finger should then be bathed mornings and evenings for a few days (e.g. a potassium permanganate solution bath for 10–15 minutes).
  • If paronychia is caused by an ingrown toenail (pictures «Ingrown toenail»4 «Ingrowing nail»5), partial avulsion of the nail followed by an application of phenol (phenolisation) often suffices as treatment.
  • In mild cases, all that is needed in addition to bathing is a topical antimicrobial cream.
  • Systemic antimicrobials are generally only indicated if cellulitis of the surrounding tissues is suspected.
  • The antimicrobials and treatment periods are the same as used in the management of an abscess: for example, cephalexin 500–750 mg three times daily for 7–10 days. Also other antimicrobials effective against S. aureus can be used: flucloxacillin 750–1 000 mg 3 times daily, or a combination of amoxicillin and clavulanic acid 875/125 mg 2 times daily

Chronic infection

  • The treatment of choice is the avoidance of exposure to moist environments and irritants.
  • Medical treatment consists of the combination of a topical glucocorticoid and either an antifungal or an antiseptic agent as a course lasting for 2–3 weeks.
  • Systemic antifungal agents may be tried in severe cases, e.g. fluconazole 150 mg once a week for 1–2 months.
  • If paronychia is of occupational origin, sick leave may be necessary.

Ingrown toenail evd

  • An ingrown toenail damages the lateral nail fold which results in pain, chronic inflammation and the formation of granulation tissue, which may sometimes be fairly extensive.
  • If bathing the toe and using well-fitting footwear does not result in improvement, the optimal treatment consists of partial avulsion of the nail combined with phenolisation.
  • This approach is more effective and less traumatic than surgical wedge resection.
  • The chronic symptoms of an ingrown toenail will not resolve with antimicrobials, and the removal of the nail margin is warranted.
  • Advice by a chiropodist regarding the correct nail cutting techniques and any noninvasive approaches (Podofix® nail brace etc.) are beneficial in the prevention of ingrown toenails. In mild cases, the chiropodist procedures may be all that is needed.

Partial nail avulsion with matrix phenolisation

  • The procedure (video «Lateral edge resection and phenolization for ingrowing toenail»1) may be performed during an acute infection and a course of antimicrobials, or during a calm phase without an antimicrobial cover.
  • Provide nerve block anaesthesia to the toe, use lidocaine without epinephrine.
  • Apply a ring tourniquet to the toe.
  • Cut a 3–5 mm section of the affected nail border with surgical scissors. Extend the cut to under the proximal nail fold. The detached nail section is lifted off complete with the germinal matrix using, for example, artery forceps. Attempt to remove the entire matrix in one piece.
  • Dry the area and insert a cotton swab (e.g. a metal shafted pin used for the cleaning of the outer ear canal) soaked with 80% phenol into the nail groove created. Repeat the application 2–3 times so that the total application time is at least one minute. Remove excessive phenol by injecting physiological saline into the wound with a syringe.
  • Remove the ring tourniquet. Apply a paraffin dressing over the wound and cover with gauze dressings. Keep the dressings in place with an elastic bandage.
  • Instruct the patient to start bathing the toe on the next day for 10–15 minutes twice a day, for as long as discharge persists.
  • An antimicrobial cream is applied after bathing.

References

  1. Tosti A, Piraccini BM, Ghetti E ym. 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):73-6. «PMID: 12077585»PubMed