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Three fractures at the base of the terminal phalanx of the finger and one at the base of the terminal phalanx of the tow were initially misdiagnosed as paronychias. If a 'paronychia' follows trauma, the possibility of a fracture should be considered and radiographs taken of the digit.
Dermatologists and other physicians frequently encounter simple chronic paronychia and onycholysis. In addition to strict avoidance of contact irritants, a broad-spectrum topical antifungal agent has been recommended. We conducted an examination of treatment with this type of agent and an assessment of the efficacy of ciclopirox 0.77% topical suspension in combination with a strict irritant-avoidance regimen. Early results of a pilot study (N = 44) using ciclopirox 0.77% topical suspension in patients diagnosed with simple chronic paronychia and/or onycholysis show excellent therapeutic outcomes of a combined regimen of a broad-spectrum topical antifungal agent such as ciclopirox and contact-irritant avoidance in this patient population.
At first glance it seemed a minor problem, but the look on my new patient's face suggested otherwise. His finger had been painful for months and this week it had become worse. His swollen, erythematous nail fold, absent cuticle, and mildly dystrophic nail painted a typical picture of chronic paronychia. Assuming an acute bacterial superinfection, I prescribed a course of antibiotics, but my patient needed advice on treatment of the underlying condition. Another general practitioner had arranged fungal cultures, which had grown candida. Would antifungals be the best treatment? My patient and I agreed to meet in a week to assess his response to the antibiotics and to discuss treatment of the underlying chronic paronychia.
Trauma to the nail folds can allow pathologic bacteria to invade this region. Once a primary, active infection has occurred in a nail fold, the area is often predisposed to chronic paronychia. Both chronic and acute paronychia are discussed, including their causes and treatments.
We report here on two retrospective studies conducted between 1982 and 1995 in 137 patients with clinical evidence of chronic paronychia or onycholysis. The purpose of the studies was to determine what factors played a role in these nail disorders. The culture results indicated that yeast commonly grew from the cultured material. Significant contact irritant exposure was frequently found. These findings and our experience suggest that the resolution of chronic paronychia and onycholysis depends on avoiding exposure to contact irritants and on appropriate treatment of any underlying fungal infection. To accomplish this latter goal, it is important to select a broad-spectrum antifungal agent that is effective against yeasts as well as other fungal pathogens.
Chronic paronychia associated with black discoloration of the left thumb nail in a 51 year old female caused by Curvularia lunata is reported for the first time. The keratolytic activity of the fungus in the nail and its complete clearance by topical clotrimazole are reported.
A total of 43 patients, 11 males and 32 females, with paronychia of the fingernails were examined for the presence of Candida spp. The yeast species isolated were identified using standard laboratory methods, including germ-tube production, morphology on rice agar with Tween 80, and mainly fermentation and assimilation of saccharides. In the male group, two Candida species were detected: C. albicans as the dominant species in 9 patients and C. parapsilosis in 2 cases. Similarly, C. albicans was the prevalent species also in females (n = 17); other Candida species detected were C. parapsilosis (n = 7), C. tropicalis (5) and C. krusei (3). In addition to the genus Candida, the following anaerobic and aerobic microorganisms were isolated from patients of both groups: Fusobacterium spp., Bacteroides spp., Staphylococcus aureus, alpha-hemolytic streptococci, group A beta-hemolytic streptococci, Klebsiella pneumoniae, Neisseria spp. and Pseudomonas aeruginosa.
We retrospectively evaluated the epidemiology of onychomycosis and/or paronychia in 172 patients attending the Clinic of Dermatology and Venereology over a 5 year period. Although yeast isolates, belonging to the Candida species, represented the most frequent etiologic agents of these infections, an increasing prevalence of fungal infections due to emerging fungal pathogens (EFP) was noted throughout this time period. In particular, EFP as causative agents of these infections increased from 0 to 28.4% from 1998 to 2002.
Cultures of paronychia of the fingers have grown aerobic and anaerobic bacteria. Each was recovered individually in only about a quarter of the patients and a mixed aerobic/anaerobic flora was isolated in half of the patients. The predominant anaerobic organisms were Gram-positive anaerobic cocci, Bacteroides species and Fusobacterium species. The predominant aerobic organisms were Staphylococcus aureus, gamma-haemolytic streptococci, Eikenella corrodens, group A beta-hemolytic streptococci, alpha-hemolytic streptococci, and Klebsiella pneumoniae. Candida albicans was recovered in about 15% of the cases. The management of this infection is discussed.
A retrospective study of cases of paronychia associated with anti-retroviral therapy diagnosed in two general hospitals is here reported. Lesions appeared from 3 and 48 months after institution of therapy. At diagnosis, 84.6% of patients were on indinavir therapy. CD4 values ranged from 120 and 1,332 cells/mm3 and viral load was lower than 200 copies/ml in 92.3 of cases. Conservative therapy was applied in 7 patients and surgery in 6. In all patients indinavir therapy was discontinued, and cure was achieved 16 weeks later. The "retinoid" effect of indinavir is discussed as likely pathogenic explanation for this complications. We advocate for topic therapy and change of anti-retroviral therapy, reserving surgery for patients not responding to therapy. Pain and functional limitation caused by this non uncommon complication (1.6% of our patients treated with anti-retroviral agents) makes its knowledge necessary and an active search by clinicians in patients receiving indinavir therapy.
A woman presenting with a history of trauma to her thumb, apparently followed by sub-acute paronychia, is subsequently shown to have primary malignant melanoma at the site. The case serves as a reminder that wolves can appear in sheep's clothing.
Mucocutaneous involvement occurs predominantly in primary systemic amyloidosis as well as in myeloma-associated systemic amyloidosis. It is rarely observed in other types of amyloidoses. Signs of such involvement may aid in the early diagnosis of the disease process. Herein, we describe a 64-year-old white male patient with myeloma-associated systemic amyloidosis in whom the disease presented with unique cutaneous lesions consisting of chronic paronychia and palmodigital erythematous swelling and induration of the hands. Following weekly regimens with prednisone (20 mg/day) and melphalan (2 mg/day) administered every 16 weeks, almost complete resolution of the cutaneous lesions was observed after 1 year of therapy. Also, in response to chemotherapy, modest regression of the myelomatous bone lesions and complete resolution of the underlying gammopathy occurred.
Blastomycosis is an unusual fungal infection in children. It is often a chronic infection characterized by granulomatous and suppurative lesions. Clinical manifestations include either pulmonary findings or disseminated disease. Disseminated blastomycosis usually begins with a lung infection that spreads to the skin, bones, and central nervous system. This is a case report of a child with chronic blastomycosis presenting with chronic paronychia, fever, cough, malaise, and back pain. The child underwent surgical drainage of a paravertebral abscess and administration of intravenous amphotericin B. He was discharged in good condition on oral therapy with ketoconazole. The literature on blastomycosis, with particular emphasis on clinical presentations and management, is reviewed. When the history and physical examination suggest a chronic granulomatous or disseminated disease, such as tuberculosis, the physician must include blastomycosis in the differential.
Bone metastases from malignant tumors are common, but metastatic lesions to the bones of the foot are very rare. The most common primary lesion is the genitourinary tract, and the tarsal bones are most commonly involved. We present a rare case of squamous cell carcinoma of the lung, metastatic to the right great toe, that presented clinically as paronychia and osteomyelitis. This was the primary manifestation of an occult and disseminated disease.
We report six HIV patients who developed painful periungual inflammation of several nails during treatment with the antiretroviral drugs indinavir and lamivudine. The lesions appeared 2-12 months after starting treatment. The occurrence of paronychia in HIV patients has recently been reported in two groups of patients receiving either indinavir or lamivudine. Dermatologists should be aware of this recently reported and probably not uncommon side-effect of antiretroviral treatment in order to avoid an invasive approach to the nail lesions.
Most infections of the upper extremity are caused by staphylococcus or streptococcus and respond well to beta-lactam antibiotics. Hand surgeons should be aware of the possible diagnosis of Mycobacterium marinum infection: 90% of the lesions are found in the upper extremity. We present a case of a chronic, cutaneous lesion of the right middle finger with synovialitis of the extensor tendons observed in a 35-year-old woman. Routine cultures from tissue of the infected finger led to the diagnosis of paronychia due to staphylococcus aureus. Despite surgical and antibacterial treatment, the lesion persisted and the patient developed multiple raised, non-tender satellite lesions to the right hand and elbow. Based on the clinical aspect and a detailed history (she kept fish and had suffered a chicken bone stab to her middle finger 12 weeks earlier), we suspected a Mycobacterium marinum infection. Tissue was obtained mainly by synovialectomy. Culture of the biopsy tissue for Mycobacterium marinum confirmed the diagnosis. The patient responded to a triple therapy (rifabutin, ethambutol and clarithromycin) and had an uncomplicated recovery. The importance of a high index of suspicion, adequate examination and a complete patient's history for a correct diagnosis is stressed. Culture for Mycobacterium marinum is not routinely performed and ought to be initiated once an infection is suspected. We also discuss the best timing for the onset of medical treatment.
HISTORY AND CLINICAL FINDINGS: A 39-year-old man was admitted for treatment of bilateral inflammatory-pustular skin changes in the area of the large toes and soles of the feet. Antibiotic treatment and an Emmert wedge resection had already been unsuccessfully performed at another hospital for what was diagnosed as paronychia. On admission there were inflammatory, in part erosive, red areas with yellow and partly confluent pustules on the distal phalanges of both great toes. The entire right nail-bed and left medial nail-bed were missing. In the area of the capillitium, both lower arms and the sulcus coronarius there were erythematous squamous plaques. INVESTIGATIONS: Radiography of the great toes demonstrated dystrophic demineralisation, in part with subchondral cystic changes of the spongiosa. Histological examination of the nail-bed showed hyperplasia and papillomatosis, definite hyperkeratosis with a prominent granular layer, as well as ortho- and parahyperkeratosis. Laboratory tests for inflammatory disease were unremarkable and there was no association with HLA B27. DIAGNOSIS, TREATMENT AND COURSE: Suppurative acrodermatitis continua of Hallopeau was diagnosed and immunosuppressive treatment with cyclosporin A given (initially 4.4 mg/kg. stepwise reduction to 2.5 mg/kg within 6 weeks, this dosage then continued for a further 10 weeks). Nearly complete healing was achieved, but the condition recurred in a mild form 2 weeks after the end of treatment. CONCLUSION: Suppurative acrodermatitis continua of Hallopeau should be included in the differential diagnosis of inflammatory changes of the distal phalanges.
BACKGROUND: The involvement of Candida in the pathogenesis of chronic paronychia (CP) has never been proven, even though this condition is commonly considered a type of Candida onychomycosis. OBJECTIVE: The purpose of this study was to compare the efficacy of systemic antifungals (itraconazole or terbinafine) with a topical corticosteroid (methylprednisolone aceponate) in the treatment of patients with CP. METHODS: The study involved 45 adult patients with CP. Medication was given in a randomized, double-blind and double dummy manner over 3 weeks. Patients were then followed for 6 weeks. Clinical and mycologic evaluations were performed at baseline, and at weeks 3 and 9. The efficacy measures included clinical and photographic evaluation. RESULTS: Of 48 nails treated with methylprednisolone aceponate, 41 were improved or cured at the end of the follow-up period. The statistical analysis showed a significant difference between the number of nails improved or cured by methylprednisolone aceponate and that of nails improved or cured with terbinafine (30 out of 57) or itraconazole (29 out of 64). Presence of Candida was not strictly linked to disease activity, and Candida eradication was associated with clinical cure in only 2 of the 18 patients who carried Candida at the beginning of the study. CONCLUSION: This study shows that topical steroids are more effective than systemic antifungals in the treatment of CP, and supports the view that CP is not a type of onychomycosis but a variety of hand dermatitis caused by environmental exposure.