Exploring The Link Between Environmental Exposure And Chronic Paronychia

Kristine Hoffman DPM

Chronic paronychia is an inflammatory reaction of the nail fold lasting more than six weeks. Many etiologies of chronic paronychia exist and they include fungal infection, contact irritants and allergens. Frequently more than one etiologic agent is present.

Chronic paronychia is prevalent in individuals whose hands or feet are frequently subject to a moist environment and contact irritants such as mild acids, mild alkalis and other chemicals. Specific populations with a higher incidence of chronic paronychia include dishwashers, laundry works, food handlers, cleaners, bartenders, fisherman, nurses and swimmers. Other predisposing factors for chronic paronychia include frequent hand washing, finger sucking and aggressive cuticle trimming.

In chronic paronychia, the cuticle separates from the nail plate, creating a portal for bacterial and fungal infection of the proximal nail fold. Studies have identified Candida albicans and various bacteria as colonizers of the nail fold in chronic paronychia.1,2 There has been debate as to the true pathophysiology of chronic paronychia. A study by Tosti and colleagues showed that topical steroids were more effective than systemic antifungals in the treatment of chronic paronychia.1 The authors suggested that chronic paronychia does not result from fungal infection but is rather a form of dermatitis resulting from environmental exposure to contact irritants.

Chronic paronychia presents with erythema, tenderness, swelling, retraction of the proximal nail fold and absence of the adjacent cuticle.2 Very longstanding paronychia can lead to changes of the nail plate with thickening, discoloration, transverse ridging and eventual nail loss.2,3 Patients with these symptoms frequently report a history of prolonged water exposure or chemical irritant exposure.

Treatment of chronic paronychia is multifactorial and involves avoiding exposure to environmental irritants and management of the resulting inflammation or infection. Various authors have shown systemic and topical antifungals and corticosteroids to be successful treatments of chronic paronychia.4-6

Daniels and colleagues have shown the broad-spectrum topical antifungal ciclopirox to be successful in the treatment of chronic paronychia and prevention of recurrence.4 Tosti and coworkers compared a three-week course of the systemic antifungal itraconazole (Sporanox, Janssen Pharmaceuticals) to a three-week course of the topical steroid methylprednisolone aceponate for the treatment of chronic paronychia.1 Significantly more patients showed improvement with the topical steroid in comparison to the oral antifungal (91 percent versus 49 percent). Given the results of this study and the risks associated with systemic antifungals, Rigopoulos and coworkers recommend using topical steroids as the first-line treatment of chronic paronychia.5 Treatment with a combination of topical steroid and topical antifungals is another option for the treatment of chronic paronychia, but data showing the superiority of this over solitary treatment with a topical steroid is lacking.6

One can treat severe paronychia and cases that fail to respond to topical treatment modalities with systemic corticosteroids and antifungals. Intralesional corticosteroid injection (triamcinolone) may be a successful treatment modality for refractory cases of chronic paronychia.3,6 Recalcitrant chronic paronychia may require surgical intervention with en bloc excision of the proximal nail fold or eponychial marsupialization.6

There is a high cure rate for chronic paronychia although resolution is slow and often requires prolonged treatment. Rigopoulos and colleagues report that mild to moderate cases of chronic paronychia frequently require nine weeks of pharmacologic treatment.5 The success of treatment is also highly dependent on the preventative measures taken to avoid contact with environmental irritants.

References

1. Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002;47(1):73-76.

2. Baran R, Barth J, Dawber RP. Nail Disorders: Common Presenting Signs, Differential Diagnosis, and Treatment. Churchill Livingstone, New York, 1991, p. 93.

3. De Berker D, Baran R, Dawber RP. Disorders of the nails. In: Burns T, Breathnach S, Cox N, Griffiths S, eds. Rook's Textbook of Dermatology, seventh edition. Blackwell Science, Oxford, 2005, p. 621.

4. Daniel CR, Daniel MP, Daniel J, Sullivan S, Bell FE. Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen. Cutis. 2004;73(1):81-5.

5. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008; 77(3):339-46.

6. Baran R. Common-sense advice for the treatment of selected nail disorders. J Eur Acad Dermatol Venereol. 2001;15(2):97-102.

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