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Foot and Ankle Surgery xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Review

Toenail paronychia
Adam Lomax *, James Thornton, Dishan Singh
Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Paronychia is an inflammation of the tissues alongside the nail. It may be acute or chronic and can be
Received 25 February 2015 seen in isolation or in association with an ingrowing toenail. Acute paronychial infections develop when
Accepted 10 September 2015 a disruption occurs between the seal of the nail fold and the nail plate, providing a portal of entry for
invading organisms.
Keywords: The treatment of paronychia associated with an ingrowing toenail is aimed at treating the causal
Paronychia toenail. In paronychia not associated with an ingrowing toenail, antibiotics may cure an early infection
Ingrowing toenail
but surgical drainage of an abscess is often required. In this case, an intra-sulcal approach is preferable to
Onychocryptosis
a nail fold incision.
Chronic paronychia is less common in the feet than in the hands. It is a form of contact dermatitis and
is frequently non-infective, however the chronically irritated tissue may become secondarily colonised
by fungi. A dermatology consultation should be obtained for suspected chronic paronychia. Patients with
chronic paronychia that is unresponsive to standard treatment should be investigated for unusual
causes, such as malignancy.
An algorithm for the treatment of paronychia is presented in this review.
Crown Copyright ß 2015 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2. Anatomy of the nail complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3. Acute paronychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.1. Acute paronychia in association with an ingrowing toe nail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.1.1. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.2. Acute paronychia not associated with ingrown toenail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.2.1. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4. Chronic paronychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
5. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

1. Introduction entry of organisms into the sulcus between the nail and nail fold
leads to bacterial or fungal infection of that area. Paronychia may
Paronychia is defined as an inflammation of the folds of tissue be acute or chronic, and the aetiology and treatment are different
(proximal or lateral) surrounding the nail of a toe or finger (Fig. 1) for each. The two forms should be considered as completely
[1]. Infective paronychia usually results from a breakdown of the separate entities.
protective barrier between the nail and the nail fold. Subsequent Much of the literature reviewed here concerns paronychia of
the finger, reflecting the paucity of literature relating to paronychia
in the toe. The presentation and treatment in the upper and lower
* Corresponding author. Tel.: +44 20 8954 2300. extremity does have many similarities. This literature is therefore,
E-mail address: 1adamlomax@gmail.com (A. Lomax). undoubtedly relevant and transferable in general terms. However,

http://dx.doi.org/10.1016/j.fas.2015.09.003
1268-7731/Crown Copyright ß 2015 Eurpoean Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
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Fig. 1. Nomenclature of the nail and nail folds. The sulcus between the nail plate and
the nail fold is invaded by organisms when the protective seal between them is
broken, resulting in an acute paronychial infection.

there are important considerations specific to the foot that must be

appreciated when managing this condition. This review presents
an overall summary of toenail paronychia along with a proposed
treatment algorithm (Fig. 2).

2. Anatomy of the nail complex

The nail complex is composed of modified cutaneous struc-

tures: nail plate, nail matrix, nail bed, proximal nail fold, lateral nail
folds. Fig. 1 illustrates the standard nomenclature used when
describing the nail complex in relation to paronychial infections.
The paronychial tissues refer generally to the lateral nail folds
(tibial and fibular) as well as the proximal nail fold (also termed
eponychium). The nail folds help to hold the nail plate in place and
provide a waterproof seal protecting against external irritants and
pathogens.
Confusingly, both the tibial and fibular nail folds are commonly
termed lateral nail folds. When performing surgery on an isolated
lateral nail fold such as for an ingrowing toenail, it is preferable to
use the term tibial or fibular nail fold to accurately specify the site.

Fig. 2. Algorithm for the management of paronychia.

3. Acute paronychia

In acute paronychia there is a rapid onset (over 2–5 days) of
discomfort, redness, swelling and tenderness of one of the nail
folds (Fig. 3a) due to a breakdown of the nail plate/nail fold barrier.
Acute paronychia of the toes is often due to ingrown nails. This is
not usually true of paronychia of the fingers, where a history of
minor nail trauma is more common. The initial inflammation may
progress to a frank bacterial infection with subsequent accumula-
tion of pus (Fig. 3b). An untreated infection may also eventually
lead to the formation of granulation tissue around the nail fold
(Fig. 3c). The most common causative infective organism is
Staphylococcus aureus, but Streptococcus, Pseudomonas species,
gram-negative bacteria and Candida albicans have all also been
isolated [2–4]. Anaerobes are more frequent in patients with
exposure of the nail to oral flora [2].
The initial abscess formation in between the nail plate and nail
fold (Fig. 4a) may track around the nail plate (Fig. 4b), becoming a
subungual abscess. This separates and elevates the nail plate from
its bed (germinal matrix in the proximal nail fold or sterile matrix
in the lateral). If the abscess tracks beneath the proximal nail plate,
it can generate enough pressure to elevate the nail plate from the
germinal matrix. Pus will then be visible underneath the nail plate
(Fig. 5a) and the nail becomes ballotable. This pressure can cause
permanent damage to the germinal matrix (Fig. 5b).
An untreated abscess in one nail fold may also track around to
involve all of the nail folds resulting in the so-called ‘‘run-around’’
infection (Fig. 6). In more advanced cases, pus may theoretically
track into other tissues of the digit. We have not however, found
any documented case of acute paronychia leading to digit pulp
abscesses, tenosynovitis or osteomyelitis in the literature.
3.1. Acute paronychia in association with an ingrowing toe nail
The term ingrowing toenail is a misnomer, since the nail plate
does not ‘‘grow’’ into the lateral nail folds. However, the term
ingrowing toenail remains in regular use both in common and
medical language. Associated factors include improperly trimmed
nails, poorly fitted shoes, tight socks, excessive sweating, soft
tissue abnormalities of the toe and inherent nail deformity [5]. It
can occur both in normal and abnormal (wide or incurvated)
toenail morphology. A common scenario is the use of fingernail
clippers to cut a relatively wide or incurvated toenail in a rounded
fashion. There is subsequent avulsion of the toenail edge, causing

Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
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Fig. 3. Initial inflammation of the lateral nail fold (a) may proceed to pus formation (b) and then to excessive granulation tissue formation (c).
traumatic separation of the nail plate from the nail fold and
occasionally leaving an edge of nail (fish hook; Fig. 3a) that
continues to act as a foreign body irritant. This causes localised
trauma and a portal of entry for infective organisms and may lead
to bacterial infection (Fig. 3b). In addition a vascular, red and
tender hyper-granulation tissue can arise from the nail sulcus
(Fig. 3c). It should also be noted that a subungual exostosis might
Fig. 4. The nail and its surrounding structures shown in cross section. The initial
abscess in the sulcus between the nail and nail fold (a) may extend around the
nail plate into the subungual region to separate and elevate the nail plate from its
matrix (b).
Fig. 5. A proximal nail fold paronychia has tracked under the nail plate to separate it
from its matrix (a), making the nail ballotable. (b) shows the indentation caused in
the nail matrix after removal of the nail, resulting from the pressure of the
accumulated pus.
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
3
cause nail deformity and present as a paronychia associated with
an ingrowing toenail (Fig. 7).
3.1.1. Treatment
In cases where an ingrown toenail is present, this must be
addressed if successful cure is to be achieved. Initial treatment for
an ingrowing nail due to a nail spike is to skilfully remove the
offending spike, often with very little discomfort. If this is too
painful, then a local anaesthetic digital nerve block can be used.
The application of an antiseptic dressing and prescription of oral
antibiotics may be necessary, particularly in diabetics and people
with poor peripheral circulation. Once the nail spike is removed,
the nail fold usually heals well [6].
If the paronychia due to an ingrowing nail is severe, recurrent or
associated with a toenail abnormality, treatment with simple
partial or complete nail avulsion without ablation has a high
recurrence rate [6,7]. In this scenario, a nail wedge avulsion and
ablation is relatively simple and very successful for long-term
relief. A number of surgical ablative procedures are performed.
Fig. 6. An abscess in one isolated nail fold may track around to involve the other nail
folds, causing a run-around infection.
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Fig. 7. A podiatrist had planned to perform a nail wedge resection for an ingrowing
toenail, but had to abandon the procedure when it was realised that the cause was a
subungal exostosis causing nail deformity.
Incisional techniques (Zadik, Winograd etc.) used for the treatment
of ingrowing toenail are not recommended in the presence of
infection [8,9]. As it is necessary to treat both the paronychia and
ingrowing toenail in combination, non-incisional techniques such
as electro cauterisation, laser surgery, or chemical agents such as
phenol or sodium hydroxide are preferable and can be performed
safely even in the presence of infection. Simple partial or complete
nail avulsion with phenol ablation (Fig. 8) has been recommended
as the treatment of choice by a recent Cochrane review of surgical
treatments [10]. The rate of recurrence is less than 5% and the
procedure can be repeated successfully in cases of recurrence.
3.2. Acute paronychia not associated with ingrown toenail
Acute paronychia not associated with ingrowing nails is much
more common in fingers than toes. This is due to the increased
Fig. 8. Nail edge avulsion followed by phenol ablation.
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
frequency of nail trauma from manicures, nail biting, biting on
hangnails etc.
There are two infective conditions of the digital tip that may
mimic acute paronychia that is not associated with an ingrowing
toenail. Again, these are usually seen in the fingers and very rarely
seen in toes. Firstly, a felon is a pulp space infection of the distal
digit, usually after minor penetrative trauma; it requires treatment
by local incision into the pulp to decompress the closed pulp space
collection. Secondly, a herpetic whitlow is a very painful infection
with the herpes simplex virus. This is sometimes accompanied by
the presence of clear vesicles. Pain is often out of proportion with
the clinical appearance. Treatment is non-operative, unless super-
imposed bacterial infection and abscess occurs.
3.2.1. Treatment
Management of acute paronychia not associated with an
ingrown toenail is largely dependent on the amount of inflamma-
tion and whether an abscess is present. In patients who present
with a minimal amount of inflammation and no abscess formation,
warm water or antiseptic soaks 3–4 times per day until symptoms
resolve is often successful [11–15]. Addition of oral antibiotics with
gram-positive coverage against Staphylococcus aureus may be
prescribed [12,16,17]. No study has been performed to evaluate the
effectiveness of soaks alone without the addition of oral
antimicrobials [18]. Coverage for anaerobes should be considered
if oral flora is suspected. In cases of known or suspected
methicillin-resistant Staphylococcus aureus, appropriate alterna-
tive therapy must be given [12,16,17].
If the paronychia does not resolve within 48 h or if it progresses
to an abscess, it should be drained [19]. In most cases, the pus may
be drained even without local anaesthesia using an intra-sulcal
technique. Drainage is achieved by introducing a blunt instrument
(e.g. haemostat/artery clamp or small elevator) into the sulcus
between the lateral nail fold and the nail plate (Fig. 9) [20,21]. This
is directed towards the site of maximal swelling and the nail fold is
elevated away from the nail until pus is released. No incision is
necessary, and upon release of the pus the cavity can be opened
with a gentle spread of an artery clamp. A fine strip of mesh gauze
may be placed into the fold to ensure continued drainage for 48 h,
followed by warm saline soaks until the erythema settles. When
Fig. 9. Intra-sulcal drainage of an acute paronychia.
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drainage is complete, antibiotics are not routinely required, but
where significant cellulitis was present, a short course of
antibiotics (flucloxacillin, clindamycin or amoxicillin plus clavu-
lanate (Augmentin) all have a wide spectrum of activity against
most pathogens isolated from paronychia) can be prescribed. The
morbidity from a separate incision directly in the nail fold can thus
be avoided.
Pus from a paronychia rarely makes its way underneath the nail
to separate the nail plate from its matrix (Fig. 4b). The presence of a
true subungual abscess in a lateral nail fold is an indication for a
nail wedge excision but this rarely occurs with an acute paronychia
that is not associated with an ingrowing toenail. The presence of
pus extending from the proximal nail fold to separate the proximal
nail plate from the germinal matrix (Fig. 5a) can be treated either
by excision of the whole nail (Fig. 5b) or by using a trephine in the
lunular region to make a hole in the nail plate to relieve pressure.
It is extremely rare for paronychial abscesses not to be
amenable to intra-sulcal drainage. In the scenario that the abscess
is pointing well away from the sulcus, a longitudinal incision is
made into the paronychium, in line with the lateral nail fold and
directly over the abscess. The blade should always be pointing
away from the nail to avoid injury to the matrix and thus avoid the
risk of nail growth deformity [12]. It is preferable to avoid incisions
made parallel to, but outside of the nail fold due to the risk of skin
bridge necrosis [12]. Complete nail removal should be reserved for
severe cases in which the entire nail is separated by spreading
infection that has undermined the whole nail plate [18].
An algorithm for the treatment of acute paronychia is presented
in Fig. 2.
4. Chronic paronychia
Chronic paronychia is an inflammatory disorder involving one
or more of the three nail folds (more commonly the proximal nail
fold) and lasting for more than 6 weeks [22]. It was previously
thought to be caused by candida infection. However, although
candida is often isolated, this is generally believed not to be a
causative pathogen [23]. Restoration of the normal barrier to
infection through treatment with topical steroids has been shown
to eradicate candida in most cases, with systemic antifungals being
shown to be of little value [24].
Chronic paronychia is a multifactorial reaction of the nail fold to
irritants and allergens. It is a form of contact dermatitis [16,25], the
aetiology of which is often complex. In the hand, patients affected
include cleaners, laundry workers, food handlers, dishwashers,
bartenders, swimmers and nurses [26]. Dermatological conditions
such as Reiter’s syndrome and pemphigus vulgaris can mimic
paronychia and medications such as retinoids, antiretrovirals,
and chemotherapeutics can cause paronychial inflammation
[22,27]. There is no literature specific to the chronic paronychia
in the foot, which is rare.
Presentation is with chronic redness, tenderness and swelling
of the nail folds without fluctuance. There may be recurrent
episodes of discharge. The nail plate may become thickened and
may be discoloured or deformed. The differential diagnosis
includes squamous cell carcinoma, malignant melanoma and
metastasis from malignant tumours. Referral to a dermatologist is
essential and management should be led by their expertise. This
may consist of irritant avoidance regimes, topical or systemic
steroids, tacrolimus ointment, and surgical en bloc excision being
reserved for recalcitrant cases [26].
Please cite this article in press as: Lomax A, et al. Toenail paronychia. Foot Ankle Surg (2015), http://dx.doi.org/10.1016/
j.fas.2015.09.003
5
5. Summary
Most cases of toenail paronychia are associated with an
ingrowing toenail and treatment should be aimed at the offending
nail. Acute paronychia not associated with an ingrowing toenail
may settle with soaks and oral antibiotics when in its early stages.
When an abscess is present, intra-sulcal drainage is recommended,
which is performed by separating the nail fold from the nail plate.
This is preferable to a nail fold incision, which should be reserved
for rare cases where the abscess points well away from the nail
plate/nail fold junction. Chronic paronychia is rare in the toes and
may be due to occupational hazards, drugs, dermatological
conditions or tumours. A dermatology consult is mandated.
Conflict of interest
None.
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