​Kembara Xtra - Medicine - Paronychia

​Kembara Xtra - Medicine - Paronychia 
Acute: characterized by pain, erythema, and swelling lasting 6 weeks; typically a bacterial infection appearing after nail biting, trauma, manicures, ingrown nails, and hangnail manipulation. Superficial inflammation of the lateral and posterior nail folds surrounding the fingernail or toenail; develops after breakdown of barrier between nail plate and the adjacent nail fold. It may be thought to be work-related in those who frequently wash their hands, such as waiters, servers, dishwashers, nurses, and bartenders. Chronic: characterized by swelling, tenderness, cuticle elevation, and nail dystrophy and separation lasting at least 6 weeks. Usually affects one finger, though drug-induced paronychia may affect multiple fingers.
Relevant anatomy includes the perionychium, nail plate, and nail bed.
Synonyms include eponychia and perionychia
Child Safety Considerations
less typical among children of all ages. Thumb- or finger-sucking is dangerous (Escherichia coli and anaerobes could be present).

Epidemiology Incidence: Predominant age range: all ages; predominance of sex: female over male; one of the most prevalent hand infections in the United States

Pathophysiology and Etiology 
Acute: 50% of cases had a mixed bacterial ecology of aerobic and anaerobic bacteria. Streptococcus pyogenes and Staphylococcus aureus are the most prevalent bacteria; Proteus vulgaris and Pseudomonas pyocyanea are less frequently found.
Chronic: secondary Candida albicans eczema reaction (95%)
 Mixed anaerobic and aerobic infections from oral flora in pediatric age groups, including Fusobacterium, Peptostreptococcus, and Streptococci
Acute paronychia of the fingers is frequently brought on by trauma, whereas acute paronychia of the toes is frequently brought on by ingrown nails (2). A paronychial infection frequently begins in the lateral nail fold.
Nail folds round up and retract as a result of recurrent inflammation, prolonged edema, and fibrosis, leaving nail grooves vulnerable to irritants, allergens, and pathogens.
Inflammation impairs the proximal nail fold's capacity to repair cuticle, which reduces vascular supply.
Topical treatments may become less effective as a result of this.
Cellulitis alone may be apparent early in the course, and if the infection is not treated right once, an abscess may develop.

Risk Elements 

Chefs, bartenders, housekeepers, swimmers, dishwashers, nurses, and others who frequently submerge their hands in water with excoriation of the lateral nail fold are examples of occupations where this occurs. Predisposing conditions include diabetes mellitus and immunosuppression. Medications include EGFR inhibitors, systemic retinoids, chemotherapy, and antiretroviral agents.

Prevention 

Acute: Steer clear of trauma like chewing your nails or fiddling with a hangnail.
Chronic: Keep your hands and fingers dry, stay away from allergens, and use rubber gloves with a cotton lining. Prevent skin from being excoriated.
Keep nails short and steer clear of manicures.
Immediately after washing your hands, moisturize.
 Effective glycemic management in diabetic patients


Eczema or atopic dermatitis, diabetes mellitus, and immunosuppression are associated conditions.

Diagnosis: Localized erythema, edema, and discomfort in the lateral or posterior nail folds.
- Acute: onset typically occurs 2 to 5 days after the incident.
- Chronic: lasting at least six weeks
Infections with herpes, prior damage (such as bites, ingrown nails, or manicured nails), exposure to allergens or irritants (such as latex or frequent immersion in water), and immunosuppressive therapy
MEDICAL ANALYSIS
Acute: posterior or lateral nail fold abscess that is red, warm, sensitive, and tense.
Chronic: - Initially manifests as a swollen, sensitive, bog-like nail fold; abscess - Later manifests as retraction of the nail fold and the absence of the adjacent healthy cuticle; thickening of the nail plate; and discoloration; many digits are often implicated.
Untreated toe infections may cause granulation tissue to grow around the nail fold, occasionally elevating the nail bed or separating the nail fold from the nail plate, fluctuance, purulence at the nail margin, or purulent discharge.
If there are secondary nail plate-like discolorations that are green in color (chloronychia), Pseudomonas should be suspected.

Differential Diagnosis: Felon (fingertip pulp abscess; immediate diagnosis essential)
Eczema and cellulitis
Herpetic whitlow (similar in appearance, extremely painful, frequently accompanied by vesicles)
 Contact dermatitis due to allergies (latex, acrylic)
 Psoriasis, particularly an intense flare-up
 Proximal/lateral onychomycosis (not mostly affecting the folds of the nail)
Acute distal phalanx osteomyelitis, Pemphigus vulgaris, retronychia, Reiter disease, and
Pustular psoriasis, dermatomyositis, and cancer, including metastatic illness and squamous cell carcinoma of the nail,

Laboratory Results 

None necessary unless the condition is severe, resistant to treatment, or if methicillin-resistant S. aureus (MRSA) is suspected, in which case: Gram stain; Culture and sensitivity; Potassium hydroxide wet mount plus fungal culture, particularly in chronic paronychia; Drugs that may affect lab results: use of over-the-counter antimicrobials or antifungals
Initial examinations (lab, imaging)
If unsure whether an abscess is present, think about getting an ultrasound.

Other/Diagnostic Procedures

 Tzanck tests or viral culture in suspected viral cases Biopsy in cases not responding to conservative care or when malignancy is suspected Incision and drainage suggested for suppurative cases or cases not responding to conservative management or empiric antibiotics

Management 
Warm water soaks or antiseptic soaks along with topical antibiotics are recommended for acute inflammation without abscess. For more severe instances that do not improve with topical therapy alone, consider oral antibiotics.
Abscesses ought to be drain.
Antibiotics might not be required for effective I&D of simple illnesses.
Chronic: Avoid contact to irritants; keep hands dry; moisturize after washing hands; improve diabetes control

First Line of Medicine
Acute paronychia (minor cases, no formation of an abscess):
- Multiple, daily 10- to 15-minute warm water soaks or antiseptic soaks (chlorhexidine, povidone-iodine), as well as topical medicines with S. aureus coverage (triple antibiotic ointment, mupirocin, bacitracin).
- Applying antibiotic cream TID-QID after a warm soak for five to ten days
- If eczematous, apply a high-potency topical steroid BID for 7 to 14 days (for example, betamethasone 0.05% cream).
 Acute paronychia (not responding to topical therapy, no formation of an abscess). for five to seven days.
- 250 mg of dicloxacillin QID
- 500 mg of cephalexin TID-QID
 Acute paronychia (oral flora exposure; absence of abscess development). 7 days of therapy. For Eikenella, a cover.
- Amoxicillin-clavulanate: pediatrics, 45 mg/kg q12h (for 40 kg); 875 mg/125 mg BID OR
- For Eikenella protection, choose one of the following:
100 mg of Doxycycline BID
Sulfamethoxazole/Trimethoprim BID
 Ciprofloxacin 500–750 mg BID (Fluoroquinolones should only be used for severe infections due to the hazards associated with this class of antibiotic.)
- Additional coverage for anaerobic conditions includes:
Metronidazole 500 mg TID; Clindamycin 300 to 450 mg TID-QID (pediatric; 10 mg/kg q8h)
 Acute paronychia (with risk factors for MRSA such as recent hospitalization, recent surgery, ESRD on hemodialysis, HIV/AIDS, IVDU, and resident in long-term care home, among others). 7 days of therapy.
- 160/800 mg BID of Trimethoprim/Sulfamethoxazole
- 100 mg of doxycycline daily
- 300 to 450 mg TID-QID of clindamycin
Consider digital block anesthesia for acute paronychia with abscess formation. - Incision and drainage. In order to assist drainage, insert a nail elevator, a no. 11 scalpel blade, or a hypodermic needle along the nail plate at the point where the afflicted nail fold and nail meet. If no drainage appears, puncture the skin right above the abscess with a needle or knife.
- Consider partial nail removal if there is an ingrown nail or an abscess that spreads to the nail bed.
- If cellulitis is spreading, consider oral antibiotics; otherwise, no antibiotics are often recommended following I&D
Stop the source of irritation, manage the inflammatory response, and restore the body's natural defenses to treat chronic paronychia.
- Betamethasone 0.05%, administered BID for 7 to 14 days; topical high-potency steroids (3)[B]
Clotrimazole or nystatin, used topically TID for up to 30 days, are topical antifungals.
-Topical calcineurin inhibitor: Tacrolimus 0.1% ointment applied BID for up to 21 days has been demonstrated to be more efficient than betamethasone, but it is more expensive.
Use doxycycline 100 mg BID to treat paronychia brought on by anti-epidermal growth factor receptor antibodies.
 Corticosteroid cream and phenol chemical matricectomy are effective treatments for paronychia brought on by cancer medication. Patients can continue receiving anticancer medication with prompt therapy without suffering a reduction in their quality of life.
Next Line
 Systemic antifungals (rarely required; use if topical treatments don't work)
- Itraconazole 200 mg for 90 days (effect may last longer due to incorporation into nail plate); pulse treatment (200 mg BID for 7 days, repeated monthly for 2 months) may also be helpful.
- Terbinafine 250 mg/day for either 12 or 6 weeks (for toenails).
Fluconazole 100 mg per day for seven to fourteen days
- Ciclopirox 0.77% topical suspension used BID for 2–4 weeks while strictly avoiding irritants  When pseudomonas is suspected, antipseudomonal medications (such as ceftazidime and aminoglycosides)
QUESTIONS FOR REFERENCE
Acute: A severe infection may extend to the underlying tendons, necessitating diagnosis and treatment by a hand surgeon. Depending on the infection's severity, débridement, washout, or amputation may be necessary.
Chronic: In situations of chronic paronychia, referral for possible partial excision of the nail fold or eponychial marsupialization with or without total nail removal or Swiss roll procedure may be considered if treatment has failed.
 Malignancy should be suspected if treatment fails to relieve symptoms or if there is persistent redness, pain, or swelling in the nail folds without an abscess. Think about biopsies.


Furthermore Treated 

Once daily application of topical betaxolol 0.25% eye drops to bandaged paronychia and pyogenic granuloma-like lesions

Procedures Incision and abscess drainage, if necessary Partial or complete nail excision with phenolization of the germinal matrix is required for a subungual abscess or an ingrown nail.
For persistent and severe acute paronychia with a runaround abscess affecting both nail folds, the Swiss roll procedure is used. Recalcitrant cases may also require nail removal.


Alternative Therapies 

Using nail bracing instead of nail extraction on patients with severe paronychia brought on by EGFR inhibitors

Take Action 

Acute: Warm soaks or antiseptic soaks are used as postdrainage treatment. After I&D, follow up is recommended 24 to 48 hours later to check for infection progression.
Avoid frequent immersion, triggers, allergies, nail biting, and finger sucking if you have a chronic condition.
Dietary and medication adjustments may be necessary if the patient has diabetes in order to improve control.

Patient Education Don't cut your cuticles, don't break your nails, and emphasize the value of maintaining good diabetic control and receiving diabetic education.
 Keep your hands away from contact irritants; use cotton liners inside rubber gloves to keep moisture out.
After washing your hands, use moisturizer; avoid biting your nails or sucking on your fingers.

Prognosis With proper care and precaution, recovery can be anticipated in 1 to 2 weeks.
Chronic paronychia may take weeks or months to respond to treatment.
If chronic lesions don't respond, there may be a benign or malignant tumor present, and dermatology referral should be taken into consideration.

Chronic complications include nail thickness, nail discolouration, and nail loss. Acute complications include subungual abscess.

---