Atlas of Primary Care Procedures, 1st Edition

Nail Procedures

33

Paronychia Surgery

A paronychia is a superficial infection or abscess of the tissues bordering the nails (i.e., nail folds). The infections develop when a disruption occurs between the seal of the proximal nail fold and the nail plate. Excessive contact with moisture or chronic irritants may predispose an individual to the development of a paronychia. Trauma such as nailbiting, manicure, or hangnail removal may also predispose to a paronychia.

Acute paronychia manifests with rapid development of erythema and swelling in the proximal or lateral nail fold. Infection withStaphylococcus aureus, streptococci, or Pseudomonas species is most common. Acute paronychia may follow a manicure or placement of sculptured nails, and it often produces tenderness and throbbing pain. Mild cases can be soaked in warm water or treated with topical or oral antibiotics (i.e., amoxicillin and clavulanic acid or clindamycin to cover oral anaerobes).

Chronic paronychia must have been present for at least 6 weeks. These lesions often develop slowly and insidiously, and they may be associated with low-grade infections with Candida albicans. Chronic paronychia are common in bakers, bartenders, dishwashers, or thumbsuckers who expose their hands to repeated or prolonged moisture and irritation. Women in the middle reproductive years are most commonly affected, with some series reporting female-to-male ratios of 10:1. Secondary nail plate changes may be found, including onycholysis (i.e., separation), lateral greenish brown discoloration, and transverse ridging.

Elimination of the offending activities or agents and treatment with antifungal agents and topical or oral corticosteroids are advocated. Although medical therapy is the mainstay of treatment for paronychia, surgical therapy provides benefit for nonresponders. Advanced cases of acute paronychia should be incised and drained. Advanced cases of chronic paronychia result in disappearance of the cuticle with retraction of the proximal nail fold from the underlying nail plate. Chronic paronychia can be treated with an eponychial excision technique or by nail removal. Almost all of the surgical procedures have medications included in the therapeutic approach.

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INDICATIONS

  • Abscess formation or severe pain in acute paronychia
  • Lack of response to medical therapy and avoidance of moisture and irritation
  • Deformity (i.e., loss of the proximal nail fold) in chronic paronychia

RELATIVE CONTRAINDICATIONS

  • Unfamiliarity of the practitioner with the techniques
  • Bleeding diathesis or coagulopathy
  • Chronic paronychia surgery in an unreliable patient or person unable to provide wound care

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PROCEDURE

A digital block is commonly performed (see Chapter 29) before surgery, although some practitioners prefer no anesthesia or a paronychia block when treating acute paronychia. The paronychia block uses a small (27- to 30-gauge) needle inserted from the lateral side near the distal interphalangeal joint, proximal to the paronychia. Administer between 1 and 3 mL of 1% lidocaine at this site.

 

(1) Paronychia block. Between 1 and 3 mL of 1% lidocaine is injected through a small-gauge needle into the lateral side near the distal interphalangeal joint, proximal to the paronychia.

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Swelling of the proximal and lateral nail fold is associated with this abscess of an acute paronychia (Figure 2A). A no. 15 scalpel blade is laid flat on top of the nail plate, with the tip of the blade directed to the center of the abscess or fluctuance (Figure 2B). Alternately, a no. 11 blade can be used, especially if additional depth of insertion is needed. The blade is guided gently along the nail surface under the nail fold, and then the tip is elevated, pulling the nail fold upward (Figure 2C). The nail plate acts as a fulcrum; pushing down on the back of the blade (or blade handle) causes the tip to elevate. A large amount of pus may drain on top of the nail plate (Figure 2D). Pus can be squeezed from beneath the nail and through the small opening. This technique has the advantage of the absence of a skin incision.

 

(2) Elevation of the nail fold allows drainage of an abscess associated with an acute paronychia.

PITFALL: Failure to elevate the tissue sufficiently may permit pus to remain in the site. Because the opening over the nail plate is small and does not involve an incision, the site can reseal and the abscess redevelop. Several sites along the nail fold may require elevation to ensure adequate drainage, and the patient should be reexamined in 2 days to check for reformation of the paronychia.

An alternate technique produces an incision through the nail fold, with drainage through the skin.

 

(3) An alternative technique is incision through the nail fold, allowing drainage through the skin.

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Chronic paronychia can be treated with excision of the proximal nail fold. After a digital block, a Freer septum elevator is used to separate the proximal nail fold from the nail plate (Figure 4A). The flat elevator is then positioned beneath the proximal nail fold to protect underlying tissues during the excision. A crescent-shaped, full-thickness incision is made in the proximal nail fold (Figure 4B). The incision extends from one lateral nail fold to the other. The island of skin to be removed is 5 mm wide (Figure 4C), incorporates the entire swollen portion of the proximal nail fold, and extends to just proximal to the proximal nail plate (Figure 4D). The side heals by secondary intention after 2 months, with the resulting nail revealing a more visible lunula.

 

(4) Treatment of chronic paronychia with excision of the proximal nail fold.

PITFALL: Meticulous wound care is required after this procedure, and the surgery is appropriate only for patients who are able and willing to provide this care. Some physicians apply a combination antifungal and steroid ointment at night and antibiotic ointment during the day until the wound heals.

An alternate technique is to remove the entire nail, placing antifungal and steroid ointment on the site daily.

 

(5) Removal of the entire nail, followed by daily application of antifungal and steroid ointment to the site.

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CODING INFORMATION

Codes for incision and drainage (I&D) are provided in the following chart.

 

CPT® Code

Description

2002 Average 50th Percentile Fee

 

10060*

I&D of abscess, paronychia, simple or single

$120

10061

I&D of abscess, paronychia, complicated or multiple

$275

 

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

Instruments used for paronychia surgery, such as no. 15 or no. 11 scalpel blades, can be obtained from local surgical supply houses. Freer septum elevators can be purchased from surgical instrument dealers or through surgical supply houses. A suggested anesthesia tray that can be used for this procedure is listed in Appendix G.

BIBLIOGRAPHY

Clark RE, Madani S, Bettencourt MS. Nail surgery. Dermatol Clin 1998;16:145–164.

Clark RE, Tope WD. Nail surgery. In: Wheeland RG, ed. Cutaneous surgery. Philadelphia: WB Saunders, 1994:375–402.

Goodheart HP. Infections: paronychia and onychomycosis. Womens Health Prim Care 1998;1:232–237.

Haneke E, Baran R. Nails: surgical aspects. In: Parish LC, Lask GP, eds. Aesthetic dermatology. New York: McGraw-Hill, 1991:236–247.

Lee S, Hendrickson MF. Paronychia. Emedicine June 20, 2002. Available at http://www.emedicine.com/derm/topic798.htm

Mayeaux EJ. Nail disorders. Prim Care 2000;27:333–351.

Parungao AJ. A swollen, draining thumb. Am Fam Physician 2002;65:105–106.

Rich P. Nail disorders: diagnosis and treatment of infectious, inflammatory, and neoplastic nail conditions. Med Clin North Am1998;82:1171–1183.

Roberge RJ, Weinstein D, Thimons MM. Perionychial infections associated with sculptured nails. Am J Emerg Med 1999;17:581–582.

Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001;63:1113–1116.

Tosti A, Piraccini BM. Treatment of common nail disorders. Dermatol Clin 2000;18:339–348.