What Is Chronic Paronychia?
Paronychia is nail inflammation resulting from trauma, irritation, or infection. This disorder can affect fingernails or toenails. Paronychia is of two types. In acute paronychia, the symptoms appear over hours or a few days, and the infection is solely in the nail fold and does not extend deeper inside the finger or toe. Conversely, chronic paronychia is a recalcitrant inflammatory disorder in which the symptoms develop more gradually than acute paronychia, usually lasting six weeks or longer and affecting several fingers or toes at once. Chronic paronychia is usually caused by irritation from environmental or occupational exposures. Less frequently, it may develop due to a chronic bacterial or fungal infection.
How Common Is Chronic Paronychia?
Chronic paronychia mainly occurs in those individuals whose hands are chronically wet, such as:
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Dishwashers.
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Dairy farmers
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Fishermen.
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Bartenders.
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Cleaners.
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Housekeepers.
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Swimmers.
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Laundry workers.
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Food handlers. Hypersensitivity to food items is responsible for increased chronic paronychia incidence in food handlers.
It can also occur if they have hand dermatitis, are diabetic, or are immunocompromised.
What Causes Chronic Paronychia?
Chronic paronychia has a complex pathogenesis and is mainly caused by multifactorial damage to the cuticle (the skin located at the base of the nail), thereby exposing the nail fold (the skin around the nail). Previously, it was thought that Candida causes chronic paronychia. However, recent data indicates that it is a type of hand dermatitis caused by environmental and occupational exposure. Furthermore, a fungus called Candida is often isolated, but in many cases, it disappears when the physiologic barrier is restored. Hence, it is concluded that chronic paronychia is an eczematous condition with a multifactorial etiology.
Rare Causes:
Some of the rare causes of chronic paronychia include:
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Raynaud's disease.
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Bacterial, mycobacterial, or viral infections.
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Papulosquamous disorders, such as psoriasis, vesiculobullous disorders-pemphigus.
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Metastatic cancer, subungual melanoma, squamous cell carcinoma.
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Drug toxicity from certain medications like retinoids, epidermal growth factor receptor inhibitors (Cetuximab), and protease inhibitors. Indinavir generates retinoid-like effects and is the most common etiology of chronic paronychia in people with HIV. Retinoids also induce chronic paronychia through the mechanism of nail fragility and minor trauma by small nail fragments.
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Paronychia has also been documented in people taking Cetuximab, an anti-epidermal growth factor receptor (EGFR) antibody used to treat solid tumors.
What Are the Symptoms of Chronic Paronychia?
Chronic paronychia is a slow process. It may begin in one nail fold, especially the proximal nail fold, but usually spreads laterally and to several other fingers. The person with chronic paronychia develops redness, tenderness, swelling, and fluid under the nail folds, along with thick, discolored nails. Each affected nail fold is lifted off the nail plate, allowing the entry of organisms and irritants. The nail plate may demonstrate thickening and longitudinal grooving. Onychomadesis (idiopathic shedding of nails from the proximal nail beds), transverse striation, pitting, and hypertrophy can happen, probably due to inflammation of the nail matrix. The nail plate may exhibit a green discoloration of its lateral margins due to colonization by Pseudomonas aeruginosa.
How Is Chronic Paronychia Diagnosed?
The health provider bases the diagnosis on the clinical symptoms and physical examination. For example, no specific test is needed to diagnose a nail infection. Occasionally, providers may take a tissue sample and send it to a laboratory to examine for specific infectious causes like bacteria or fungi. Rarely, for severe infections, imaging like an X-ray may be ordered to inspect for the involvement of the underlying bone. The provider should evaluate the possibility of squamous cell carcinoma of the nail, malignant melanoma, and metastases from malignant tumors when paronychia is unresponsive to treatment. Prompt biopsy should be done in such cases.
What Is the Treatment for Chronic Paronychia?
1. General Measures:
Self-care measures help in prevention and work synergistically with other active efforts to improve the healing time and decrease further paronychia recurrences. The main aim is to avoid aggravating factors and minimize further injury by reducing the manipulation of the nail. The following tips may benefit:
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Avoid prolonged exposure to moist environments and contact irritants, including harsh soaps and detergents.
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Keep the hands dry and warm.
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Maintain proper hygiene by washing your hands with gentle soaps.
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Keep the nails clean.
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Apply moisturizer after washing hands.
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Wear waterproof gloves lined with cotton while performing any work with potential exposure to irritants.
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Keep the nails short to minimize further injuries and avoid nail manipulation, such as finger sucking, biting or chewing nails, manicuring, or attempting to incise and drain the lesion.
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Choose the right kind of footwear to avoid unnecessary damage to the nail.
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People with diabetes should maintain strict glycemic control.
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Avoid cutting too near to the nail fold when trimming cuticles.
2. Medical Treatment:
Treatment focuses on dermatitis and includes the following medications:
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Topical corticosteroid ointment is applied for two to four weeks and repeated for flares.
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Tacrolimus ointment (a calcineurin inhibitor) is an alternative when dermatitis is unresponsive to routine management.
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Intralesional corticosteroid injections are sometimes used in resistant cases.
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Oral antifungal agents such as Itraconazole or fluconazole are added to therapy if Candida albicans are confirmed.
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For severe or refractory disease, surgery
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Severe or refractory cases may need surgery.
3. Other Management:
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People with diabetes and vascular disease with toenail paronychia must be examined for signs of cellulitis.
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Eponychial marsupialization involves the surgical removal of a narrow skin strip next to the nail to decrease the risk of infection.
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The Swiss roll technique helps retain the nail plate and faster recovery.
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Surgical management is only recommended in recalcitrant cases of chronic paronychia, unresponsive to medical treatment, and proper use of general measures. Surgical treatment removes the chronically inflamed tissue, which assists in adequately penetrating topical and oral medications and regeneration of the cuticle.
What Are the Complications of Chronic Paronychia?
The major complication of chronic paronychia is nail dystrophy. It is usually associated with distorted, ridged nail plates. The nail plates may turn yellow, green, or black and brittle. After recovery, it may take up to a year for the nails to return to normal. See a healthcare provider if symptoms are severe or do not disappear after a couple of days or if the symptoms return after medical treatment.
Conclusion
Paronychia infections can be painful and uncomfortable but do not usually cause serious health problems. Chronic paronychia is mainly a kind of hand dermatitis, not a fungal infection. Steroids are more effective than antifungals in the management of chronic paronychia. Surgery is indicated only for recalcitrant cases. Seek treatment immediately if paronychia returns after treatment or if the symptoms worsen or do not go away.
