Chronic paronychia is not a primary infection Chronic paronychia of the hands is typically intiated by frequent immersion of hands in water

of clothes. Clinically, the proximal and lateral nail folds show erythema and swelling. The cuticle is lost and the ventral portion of the proximal nail fold becomes separated from the nail plate. This newly formed space has an important additional role in maintaining and aggravating chronic paronychia—it becomes a receptacle for microorganisms and environmental particles that potentiate the chronic inflammation. With time the nail fold retracts and becomes thickened and rounded.

The course of chronic paronychia is interspersed with self-limiting episodes of painful acute inflammation. The acute exacerbations of chronic paronychia may be due to secondary candidal and bacterial infections, with small abscesses resulting at the depth of the space between the proximal nail fold and the nail plate. These microbial abscesses drain spontaneously and this explains why such bacterial exacerbations subside without treatment in a few days.

Acute exacerbations of chronic paronychia are not only due to microbial colonization, but can also be caused by irritants or allergens that penetrate deep to the proximal nail fold. In occupational paronychia, foreign material such as wax, hair, foodstuffs and debris may collect in the proximal nail fold. This may cause retraction of the nail fold and persistence of the process. In the early stages the nail plate is unaffected, but one or both lateral edges may develop irregularities and yellow, brown or blackish discoloration; this may extend over a large portion of the nail, and occasionally the whole nail may become involved. It is believed to follow discoloration caused by dihydroxyacetone produced by the organisms in the nail fold. In contrast, Pseudomonas infection often produces a greenish discoloration. The lateral discoloured edges of the nail plate become cross-ridged when the disease mainly affects the lateral nail fold. On the surface, which often becomes rough and friable, numerous irregular transverse ridges or waves appear as a result of repeated acute exacerbations. Eventually the size of the nail is considerably reduced, an effect exaggerated by the swelling of the surrounding soft tissues. The pathology of chronic paronychia reveals spongiotic dermatitis of the ventral portion of the proximal nail fold.

Proximal Detachment The Nail

Figure 5.3

Chronic paronychia due to constant wetting.

Figure 5.3

Chronic paronychia due to constant wetting.

There is some disagreement as to the importance of yeasts in chronic Candida paronychia; this organism may be commensal or pathogenic. Candida hypersensitivity is a similar reaction to that observed in some patients with recurrent vaginitis.

The various factors that damage the area allow Staphylococcus aureus and Candida species to attack the keratin and cause the detachment of the cuticle from the nail plate. In children the most common predisposing factor to chronic candidal paronychia is the habit of thumb or finger sucking. This is potentially more harmful than occupational immersion, as saliva is more irritating than water. Paronychia may also develop in people with eczema or psoriasis involving the nail folds. Although infrequent, chronic paronychia of the toe nails may develop in association with diabetes mellitus or peripheral vascular disease, both of which should be excluded unless ingrowing nail is present.

Differential diagnosis

Chronic paronychia can be associated with nail infections caused by various species of Scytalidium. Brown discoloration starting at the lateral edges of the nail and spreading centrally into the nail is seen in some cases. Rarely this is caused by separate Candida infection which is not directly related to the original Scytalidium infection. In white people, Fusarium oxysporum may produce chronic paronychia in finger or toe nails.

Syphilitic paronychia is due to a chancre on the perionychial area; it is usually painful. Pemphigus may produce considerable bolstering of the nail fold and closely resembles chronic paronychia with accompanying onychomycosis. Parakeratosis pustulosa (Hjorth-Sabouraud syndrome) may also mimic fungal paronychia. Psoriatic lesions, Reiter's syndrome and eczema sometimes involve the proximal nail fold. Secondary bacterial or yeast infections may develop in the area.

Treatment

If chronic paronychia becomes recalcitrant and unresponsive to medical procedures, most often after penetration of foreign bodies such as hair, bristle or wood splinters, then surgical removal of the proximal nail fold and proximal lateral nail folds together with the proximal nail plate may be required; after this procedure complete healing normally takes approximately 8 weeks.

Table 5.1 shows the principal causes of paronychia (Figures 5.1-5.11). Acute paronychia is most commonly seen in nail biters, while the most frequently seen type of chronic paronychia is that occurring on the hands of domestic and office cleaners and bar staff (wet work) (see Figure 5.3).

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