the distal edge of the nail, a prick from a thorn in a lateral groove, or sometimes from subungual infection secondary to haematoma (Figures 5.1, 5.2).
The infection begins in the lateral paronychial areas with local redness, swelling and pain. At this stage medical treatment is indicated: wet compresses (for example with Burrow's aluminium acetate solution) and appropriate systemic antibiotic therapy are given. Because the continuation of antibiotics may mask a developing pathological process that can damage the nail apparatus, if acute paronychia does not show clear signs of response within 2 days then surgical treatment should be instituted under proximal block local anaesthesia. The purulent reaction may take several days to localize and during this time throbbing pain is always a major symptom. The collection of pus may easily be seen through the nail or at the paronychial fold. Sometimes a bead of pus may be present in the periungual groove. In the absence of visible pus, the gathering gives rise to tension and the lesion should be incised at the site of maximum pain, not necessarily at the site of maximum swelling. In practice, Bunell's technique is usually successful: the base of the nail (the proximal third) is removed by cutting across with pointed scissors. A non-adherent gauze wick is laid under the proximal nail fold. If the paronychial infection remains restricted to one side, removal of the ipsilateral part of the nail is sufficient.
Bacterial culture and sensitivity studies are mandatory. The bacteria most commonly found in acute paronychia are staphylococci and, less commonly, p-haemolytic streptococci and Gram-negative enteric bacteria. Should surgical intervention be delayed, the pus will track around the base of the nail under the proximal nail fold and inflame the matrix; it may then be responsible for transient or permanent dystrophy of the nail plate. It is essential to note that the nail matrix in early childhood is particularly fragile and can be destroyed within 48 hours by acute bacterial infection. The pus may also separate the nail from its loose, underlying proximal attachment. The firmer attachment of the nail at the distal border of the lunula may temporarily limit the spread of the pus. In cases with extension of the infection under the distal nail bed, the whole of the nail base should be removed with nail removed distally to expose fully the involved nail bed.
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