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Paronychia

What is Paronychia

A “paronychia” (pare-oh-nick-ee-ah) is an infection of the skin around a fingernail or toenail. The infection almost always starts because the nail is “ingrown.” Ingrown nails happen when one corner of the growing nail digs into the skin at the tip of the finger or toe. The most common cause of ingrown nails is cutting the nail too short. If a person cuts the nail off shorter than the end of the finger or toe, it may push into the skin as it grows. In some cases tight or pointed shoes can put enough pressure on a toenail to force it to ingrow.

Once the nail is ingrown, an infection is very likely, because the skin becomes irritated and broken. Dirt on the nail then becomes pushed into the skin, and sets off the infection. Many children first respond to the discomfort of an ingrown nail by digging at it, chewing on it, or trying to cut the nail shorter. All of these things, of course, only increase the amount of dirt and germs in the area.

Early signs of an ingrowing nail are pain or pressure at the tip of the finger or toe. Children and teens often mistake this discomfort for a blister or the result of a tight shoe. They may ignore it at first. As the nail grows in deeper it becomes harder to ignore. The skin around the nail becomes red, swollen, and tender. A small amount of clear or yellow fluid may start to leak from the fold where the skin and the nail meet. After a few more days, the area becomes even more red and swollen, and you can usually see white or yellow pus under the skin along the nail. Sometimes the pus pushes its way under the nail as well. Without treatment, the infection can spread to the lymph ducts, and you can see red streaks going up the hand or foot. If an infection reaches this stage, it can be quite dangerous. In most cases, children and teens will seek help before this point.

 What is the biggest concern?

The child’s main concern at first is usually the pain. Older children and teens may not tell you about the problem at first just because they think it will go away. Once the redness and swelling become noticeable, the main concern is stopping the infection and getting the ingrown nail out of the tissue. If infection spreads to the tissue of the hand or foot, or spreads to the lymph ducts, there is some risk of blood poisoning, or “septicemia.”

Paronychia treatment

As with any infection, we treat a paronychia with antibiotics to kill the germs, and by getting rid of as much of the infected material as possible. If you and your child catch the infection early, while it is still only red and there’s no pus, you might be successful treating just with antibiotics and some local care such as warm soaks. Even so, the doctor may need to remove at least part of the nail to prevent the infection from returning.

Once pus appears in the infected area, your doctor will have to remove some or all of the nail. Some doctors prefer to remove the entire nail, which may help the new nail grow back more smoothly. Others prefer to remove only the piece of the nail that is causing the problem. Either way, the doctor will give a local anesthetic by injection. This stings for a few seconds, but then the entire finger or toe will be numb, and the rest of the procedure will be painless. If you are reading this before your child goes in for that procedure, please encourage him or her to let the doctor know if s/he feels pain. It is almost always possible to give enough anesthetic to make the finger or toe completely numb. Younger children may be so frightened by the procedure and the injection that they cry and struggle through the whole thing. You and your doctor will decide together whether your child is having pain as well.

After the doctor removes the nail, s/he will wash the area with saline (salt) solution to clean it out. Some doctors put a small amount of gauze packing into the area. Some doctors also put the nail back in place loosely. Doctors often give antibiotics for 5 to 10 days to help cure the infection. As always, please be sure to finish the entire antibiotic prescription and to give every dose on schedule. This will prevent recurrence of the infection.

Once the procedure is over, the doctor will wrap the wound with gauze or another bandage. If the paronychia was on a toe, your child may need crutches for a few days. Please have your child wear an open-toed sandal or flip-flop, and either no sock or just a white cotton sock. This will help keep the area dry. Definitely do not have your child wear a closed shoe or sneaker, which could promote more serious infection.

Dangerous Paronychia Symptoms?

Most ingrown nails and infections heal well with local care and antibiotics. A serious infection is possible, especially in children with immune system disorders or children who take immune suppressing medications. Here are some things to look out for:

  • Fever
  • Expanding area of redness or swelling after the removal of the nail and after starting antibiotics
  • New or persistent pain in the area
  • Red streaks spreading up the hand, arm, foot, or leg
  • Pain in the armpit or groin area on the same side as the infection

If any of these occur, please be sure to call your doctor’s office right away.

Other points of concern

Some children tend to get ingrown nails and infections repeatedly. Most often this is the result of incorrect nail care. Please be sure that your child or teen understands that s/he must let the nail grow out past the tip of the finger or toe. This will make it impossible for the nail to grown in and cause infection. It also helps to avoid narrow or pointy shoes.

Other Conditions that Might Be Present

There are a few conditions that look a bit like paronychia but are not. It’s important to know what to look for so that you can let your doctor know if the treatment you are using doesn’t help. A “felon” is an infection of the deeper part of the finger tip, called the finger pad. There’s usually not pus around the nail, and the finger pad is swollen and very tender. Pressure can build up in a felon and a bone infection can set in, so if there’s swelling of the finger pad or tenderness there, please let your doctor know.

Children with a first-time (so-called “primary”) herpes virus infection in their mouth can develop sores on the tips of their fingers that can look almost exactly like a paronychia. This is called “whitlow.” It is best not to do any surgical procedure on this condition. Children with whitlow usually have had obvious mouth sores some days earlier. Teenagers can develop whitlow on their fingers from primary oral or genital herpes. Please be sure to let your doctor know if your child or teen has had a herpes infection.

Sometimes a fungal infection similar to athlete’s foot can cause inflammation around the nail. This can also look like a paronychia. Most doctors prefer to treat these infections with anti-fungal medicine and avoid surgical procedures as well.