Hurst et al.

23. Fischer P. Herpetic whitlow and Tzanck preparation.J Fam Pract 1986;23:204.

24. Solomon A, Rasmussen J, Vanani J, Pierson C. TheTzanck smear in the diagnosis of cutaneous herpes sim­plex. JAMA 1984;251:633-5.

25. Baker D, Blyth JG, Kaufman RH. One-year suppressionof frequent recurrences of genital herpes with oral acy­clovir. Obstet Gynecol 1989;73:84-7.

26. Laskin O. Acyclovir and suppression of frequently re­curring herpetic whitlow. Ann Int Med 1985;102(4):494-5.

The Journal ofHAND SURGERY

27. Schwandt N, Mjos D, Lubow R. Acyclovir and the treat­ment of herpetic whitlow. Oral Surg Oral Med Oral Pa­thol 1987;64(2):255-8.

28. Sands M, Brown R. Herpes simplex lymphangitis. ArchIntern Med 1988;148:2066-7.

29. Polayes I, Arons M. The treatment of herpetic whitlow­a new surgical concept. Plast Reconstr Surg 1980;65:811-17.

Eponychial marsupialization and nail removal forsurgical treatment of chronic paronychia

A long-term retrospective study of patients with chronic paronychia treated by eponychlal mar­supialization with or without nail removal is presented. Twenty-eight consecutlve fingers withchronic paronychia in twenty-five patients were surgically treated. Symptoms had been presentfor 28 ± 7 weeks. Twenty-three of these had nail irregularities. Of this group, the first sevenfingers were treated with marsupialization alone. Recurrences developed in two of these. Thenext sixteen patients with nail irregularities were treated with marsupialization plus nail removal,and there were no recurrences (p < 0.05). Furthermore, when the two recurrent paronychiawere treated with both procedures, one healed completely and the other was markedly improved.All fingers without nail irregularities healed with marsupialization alone. These results confirmthat eponychial marsupialization is an effective means of treating chronic paronychia and suggestthat nail removal should be done when concurrent nail irregularities are seen (J HAND SURG1991;16A:314-17.)

Michael S. Bednar, MD, New York, N.Y., and Lewis B. Lane, MD, Manhasset. N.Y.

Chronic paronychia is characterized byinduration and rounding of the eponychium, recurringepisodes of acute eponychial inflammation and drain­age, and eventual thickening and longitudinal grooving

From the Section of Hand Surgery, Department of Orthopaedics. TheHospital for Special Surgery N. Y., N. Y.; and from the Departmentof Surgery, Division of Orthopaedic Surgery, North Shore Uni­versity Hospital-Cornell University Medical College, Manhasset,N.Y.

Read at the Annual Meeting of the American Association for HandSurgery, San Francisco, California, September 28, 1989.

Received for publication Dec. 19, 1989; accepted in revised formMarch 22, 1990.

No benefits in any form have been received or will be received froma commercial party related directly or indirectly to the subject ofthis article.

Reprint requests: Lewis B. Lane, MD, 800 Community Dr., Man­hasset, NY 11030.

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314 THE JOURNAL OF HAND SURGERY

of the nail. It ranks with fungal infection and psoriasisas the most common causes of nail disease. I It is mostcommon in 30- to 60-year-old women" and occurs mostfrequently in people whose hands are exposed exces­sively to water, such as housewives and bartenders.!Numerous conservtive treatments, including vasodila­tors and oral and topical antibacterial and antifungalagents, have met with limited success. Conversely, thesurgical technique of eponychial marsupialization re­ported by Keyser and Eaton' has been highly effective.They stated that nail removal was not necessary to curechronic paronychia. Our study examined the effective­ness of marsupialization and determined if nail removalwould increase the cure rate.

Materials and methods

Twenty-eight consecutive fingers with chronic par­onychia in twenty-five patients were surgically treatedby the senior author. The average patient age was44 ± 3 years (x ± SE) (range, 21 to 67), and the

Vol. 16A, No.2March 1991 Treatment of chronic paronychia 315

Fig. 1. A, Preoperative photograph of a patient with chronic paronychia of the left long finger withplanned surgical incision: Note the nail irregularity and swelling of the eponychium. B, Immediatepostoperative appearance with operative specimens. CoD, Thirty-one months after marsupializationand nail plate removal erythema and swelling of the paronychia are gone and the nail is smooth .

female-to-male ratio was 4: 1. The duration of symp­toms was' 28 ± 7 weeks, (range, 4 to 107). All 28fingers had swelling, tenderness, and erythema at the

'proximal eponychium. Fourteen of these also had ulnaror radial paronychium involvement. Only two fingershad serous drainage. Nail irregularities consisting ofridging, discoloration, poor adherence and/or longi­tudinal groove formation were present in 23 fingers.Sixteen fingers had received previous treatment con­sisting of oral antibiotics (10), ointments (2), or nailremoval (4), without relief of symptoms.

The dorsal roof of the nail fold was marsupializedin all fingers (see Fig. 1, A and B). A crescent of skinparallel to the eponychium and extending from the ra-

dial to ulnar borders was excised. The width of thecrescent was 3 mm from proximal to distal edge. Incontrast to the technique of Keyser and Eaton in whichall thickened tissue is removed with the skin, the sub­cutaneous tissue and fat were left intact in these pa­tients. In addition to marsupialization, in our studycomplete or partial nail removal was also done in 18patients with nail irregularities.

After operation, all wounds were covered with Xe­roform gauze (fine mesh absorbent gauze impregnatedwith 3% bismuth tribromophenate in a petroleum blend[Sterile Products Corp., Valley Park, Mo.]) . When thenail was removed, the gauze was placed within the nailfold. Patients were instructed to soak the finger in hy-

316 Bednar and LaneThe Journal of

HAND SURGERY

Fig. 2. Diagram of nail and nail bed. (A) Nail; (8) Eponychium ; (e) Dorsal roof of nail fold; (D)Ventral floor of nail fold, also called germinal matrix; (E) Nail bed, also calIed sterile matrix. Thevast majority of the nail is produced in the ventral floor. The dorsal roof is responsible for the 'smooth, shiny surface.

drogen peroxide followed by washing in chlorhexidinegluconate skin cleanser (Hibiclens, Stuart Pharmaceu­ticals, Wilmington, Del.) or hexachlorophene detergentcleanser (pHisoHex, Winthrop-Breon, New York,N. Y.) 3 times per day beginning on the third postop­erative day until all drainage stopped. All patients re­ceived oral cephalexin (Keflex) 500 mg 4 times dailyor oral erythromycin 500 mg 4 times daily if allergicto penicillin. If an appropriate oral antibiotic was iden­tified against the cultured organism, the patient wasmaintained on the drug for 14 days. If no appropriateantibiotic was found or the cultures were negative, theantibiotics were stopped at 3 to 5 days .

Statistical analysis was done by the chi square test.Follow-up averaged 33 months.

Results

Overall, the paronychia was cured in 27 of28 fingers.Cure was defined as absence of swelling, tenderness,and redness, and presence of a 'normal nail.

Of the 23 fingers that were seen with nail irregular­ities, the first 7 were treated with marsupializationalone . In two of these seven recurrent paronychia de­veloped. In the subsequent 16 patients who were alltreated with marsupialization and nail removal therewere no recurrences (p < 0.05). The typical appear-

Table I. Operative cultures fromthirteen patients

Organism

Gram-positive cocciGram-negative rodsCandidaMycobacteria

Number of cultures

7422

ance of a patient treated with marsupialization and nailremoval at 31 months after operation can be seen inFig. I, C and D.

The two fingers that had development of recurrentparonychia were retreated by marsupialization and nailremoval. One was cured and the other retained somenail irregularity and chronic mild tenderness withouterythema or swelling.

Finally, the five fingers that were seen without nailirregularities were cured by marsupialization alone.

Microbial organisms were successfully cultured in13 cases and are listed in Table 1. Positive cultureswere not recovered from the other cases. When culturedorganisms were not sensitive to oral antibiotics anti­biotics were stopped. There was no correlation betweencultures, sensitivities, and outcome.

Discussion

A possible explanation for the improved cure witheponychial marsupialization plus nail removal may befound by reviewing the pathophysiology of chronic par­onychia. The condition most likely begins as a sepa ­ration of the nail fold from the underlying hard keratinof the nail caused by trauma or immersion in water ordetergents. This area is probably first colonized byStaphylococcus pyogenes and/or S. epidermidis. Theseorganisms may allow for further infection with Candidaalbicans and colonic gram-negative bacteria, which aremore commonly cultured from chronic paronychla.t"In this study, our patients grew a mixed flora.

Stone and Mullins?' 8 showed that viable and non­viable C. albicans introduced into a chronically ma­cerated nail fold can produce a chronic paronychia. Alow-grade chronic inflammatory response is set up,leading to fibrosis and thickening of the eponychium.

Vol. 16A. No.2March 1991

This in tum decreases the vascular supply to the nailfold decreasing resistance to minor bacterial infections.This explains why chronic paronychia are subject torecurrent flares with drainage. It may explain why con­servative therapy often fails; topical antibiotics cannotpenetrate chronically inflammed skin and systemicdrugs cannot be delivered to areas ofdecreased vascularsupply."

Nail deformity is caused by the inflammation inter­fering with the formation of the nail. The vast majorityof the nail is produced in the germinal matrix locatedin the nail fold ventral floor." The dorsal roof is re­sponsible for the shiny surface of the nail. Baran andBaruea 10 suggested complete removal of the dorsal roofincluding the eponychium for the treatment of chronicparonychia. Since the shiny surface of the nail is pro­duced by the dorsal nail fold, their procedure can leadto dulling and roughing of the nail as well as a con­tracted eponychium. (See' Fig. 2.)

Ridging and pitting of the nail is probably secondaryto inflammation in the region of the germinal matrix.Eponychial marsupialization, however, only drains thedorsal surface of the dorsal roof. We believe that nailremoval more thoroughly debrides the entire nail foldby permitting drainage of the volar portion of the dorsalroof as well as the ventral floor.

In summary, we concur with Keyser and Eaton thateponychial marsupialization is an effective means oftreating chronic paronychia. Our results also indicate

Treatment of chronic paronychia 317

that nail removal should be performed when concurrentnail irregularities are seen.

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2. Whittle HC, Moffatt Jl., Davis RA. Paronychia or peri­onychia: aetiological aspects. Br 1 Dermat 1959;71:1-1 I.

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