Paronychia Surgery

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Introduction

Paronychia is a superficial infection or abscess of the tissues bordering the nails (i.e., nail folds). It is one of the most common infections of the hand. 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 nail biting, manicure, a splinter or thorn in the distal edge of the nail, or a hangnail removal may also predispose a patient to a paronychia. 
Acute paronychia manifests with rapid development of erythema and swelling in the proximal or lateral nail fold. Infection with Staphylococcus 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 by definition must have been present for at least 6 weeks. These lesions often develop insidiously, and they may be associated with low-grade infections with Candida albicans. Chronic paronychia is common in bakers, bartenders, dishwashers, or thumb suckers 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 (such as miconazole or ketoconazole) and topical or oral corticosteroids are advocated for chronic paronychia. Although medical therapy is the mainstay of treatment for chronic paronychia, surgical therapy may provide benefit for nonresponders. The most common surgical technique used to treat chronic paronychia is called eponychial marsupialization. Advanced cases of acute paronychia should be incised and drained. Advanced cases of paronychia result in disappearance of the cuticle with retraction of the proximal nail fold from the underlying nail plate. 

Equipment

  • A recommended anesthesia tray is shown in Appendix F.

  • A typical surgical tray is shown in Appendix G.

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

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

The Procedure

Step 1

A digital block is commonly performed (see Digital Nerve Block Anesthesia) 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. 

Step 2

Swelling of the proximal and lateral nail fold is associated with this abscess of an acute paronychia. A no. 11 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. The blade is guided quickly but gently into the nail surface under the nail fold, and then the tip is elevated, pulling the nail fold upward. 

Step 3

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. 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. 
  • 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 can redevelop. Several sites along the nail fold may require elevation to ensure adequate drainage, and the patient should be re-examined in 2 days to check for reformation of the paronychia.

Step 4

Recalcitrant chronical paronychia can be treated with excision of the proximal nail fold. After a digital block, a Freer septum elevator or the jaw of a hemostat is used to separate the proximal nail fold from the nail plate. 
  • Pearl: The flat elevator may then position beneath the proximal nail fold to protect underlying tissues during the excision.

Step 5

A crescent-shaped, full-thickness incision is made in the proximal nail fold. The incision extends from one lateral nail fold to the other. 

Step 6

The island of skin to be removed is 3–5 mm wide, incorporates the entire swollen portion of the proximal nail fold, and extends to just proximal to the proximal nail plate. The side heals by secondary intention after about 2 months, with the resulting nail revealing a more visible lunula. 
  • 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.

Complications

  • Paronychial infections may spread

  • Felon

  • Secondary ridging, thickening, and discoloration of the nail

  • Nail loss (rare)

Pediatric Considerations

Children who bite their nails are more prone to paronychia. Behavioral modification may be necessary to prevent recurrences. 

Postprocedure Instructions

The dressing should be removed in 48 hours. Then start warm water soaks four times a day for 15 minutes with gentle massage to express any collected pus. Between soakings, an adhesive bandage should be placed over the nail area. Antibiotic therapy is usually not necessary. 

Coding Information and Supply Sources

Common ICD-9 Codes

Instrument and Materials Ordering

  • Instruments used for paronychia surgery, such as 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 F.

Bibliography

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2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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