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Patient Story
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A teenage girl presents with mild itching and redness in her finger nail folds (Figure 164-1). The pediatrician diagnosed her with chronic paronychia, probably due to chronically pushing back her cuticles for cosmetic reasons. Behavior modification resulted in resolution of symptoms.

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FIGURE 164-1

Chronic paronychia in a teenage girl probably due to chronically pushing back her cuticles for cosmetic reasons. Note the redness in the finger nail folds. (Used with permission from Richard P. Usatine, MD.)

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Introduction
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Paronychia is a localized, superficial infection or abscess of the nail folds. Paronychia can be acute or chronic. Acute paronychia usually presents as an acutely painful abscess in the nail fold. It is most commonly treated with incision and drainage (Figure 164-2). Chronic paronychia is defined as bring present for longer then 6 weeks duration. It is a generalized red, tender, swelling of the proximal or lateral nail folds. It is usually nonsuppurative and is more difficult to treat.

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FIGURE 164-2

Incision and drainage of the acute paronychia with a #11 scalpel. Note the exuberant pus draining from the incision. (Used with permission from Richard P. Usatine, MD.)

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Epidemiology
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Paronychia is the most common infection of the hand representing 35 percent of all hand infections in the US.1

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Etiology and Pathophysiology
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  • Paronychial infections develop when a disruption occurs between the seal of the nail fold and the nail plate or the skin of a nail fold is disrupted and allows a portal of entry for invading organisms.2

  • Acute paronychia is most commonly caused by S. aureus, followed by Streptococcus pyogenes Pseudomonas pyocyanea, and Proteus vulgaris.3

  • Chronic paronychia is thought to be a multifactorial inflammatory and/or allergic phenomenon in which a variety of microorganisms, including bacteria and fungi, may be secondarily present.4

  • Untreated persistent chronic paronychia may cause horizontal ridging, undulations and other changes to the nail plate (Figures 164-3 and 164-4).

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FIGURE 164-3

Chronic paronychia. Note horizontal ridges on one side of the nail plate as a result of chronic inflammation. (Used with permission from Richard P. Usatine, MD.)

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FIGURE 164-4

Chronic Candida paronychia causing a dysmorphic fingernail with horizontal ridging. (Used with permission from Richard P. Usatine, MD.)

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Risk Factors
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