Dr Shweta B Nanjannavar
Paronychia is one of the common infections of the hand. The term para, “around”, onyx, “nail” which refers about infection around the nail .Clinically, paronychia presents as an acute or a chronic condition. It is a localized, superficial infection or abscess of the paronychial tissues of the hands or, less commonly, the feet. Any disruption of the seal between the proximal nail fold and the nail plate can cause acute infections of the eponychial space by providing a portal of entry for bacteria.
Nail or nail bed problems can be seen in any age group, but it is commonly seen more in females than males. Noninfectious causes of paronychia include contact of irritants and excessive moisture. Clinically, paronychia presents as an acute or chronic condition. People with occupations such as baker, bartender, farmer and dishwasher seem predisposed to developing chronic paronychia1.
Components of the nail complex include the nail bed , the nail plate and the perionychium. The nail bed lies beneath the nail plate and contains the blood vessels and nerves. The nail plate is hard and translucent, and is composed of dead keratin. The plate is surrounded by the perionychium, which consists of proximal and lateral nail folds, and the hyponychium, the area beneath the free edge of the nail7
Acute paronychia most commonly results from nail biting, finger sucking, aggressive manicuring, a hang nail or penetrating trauma, with or without retained foreign body . Sculptured fingernail (artificial nail) placement has also been shown to be associated with the development of paronychia. The most common infecting organism is Staphylococcus aureus, followed by streptococci and pseudomonas organisms. Gramnegative organisms, herpes simplex virus, dermatophytes and yeasts have also been reported as causative agents8.
Chronic paronychia is an inflammatory recalcitrant disorder affecting the nail folds. It can be defined as an inflammation lasting for more than 6 weeks and involving one or more of the three nail folds (one proximal and two lateral9.
Repeated bouts of inflammation, persistent edema, induration, and fibrosis of proximal and lateral nail folds causes the nail folds to round up and retract, thereby exposing the nail grooves further. This loss of an effective seal leads to a persistent retention of moisture, infective organisms and irritants within the grooves, in turn exacerbating the acute flare-ups. This vicious cycle goes on, compromising the ability to regenerate the cuticle. The inflamed and fibrosed PNF progressively loses its vascular supply .This is responsible for failure of medical treatment measures. Topical drugs fail to penetrate chronically inflamed skin, and systemic drugs cannot be delivered to areas of decreased vascular supply.10
Chronic paronychia usually causes swollen, red, tender and boggy nail folds .Symptoms are classically present for six weeks or longer. Inflammation, pain and swelling may occur episodically, often after exposure to water or a moist environment. Eventually, the nail plates become thickened and discolored, with pronounced transverse ridges. The cuticles and nail folds may separate from the nail plate, forming a space for various microbes, especially Candida albicans, to invade.
Management of chronic paronychia primarily involves avoiding predisposing factors such as exposure to irritating substances, prolonged exposure to water, manicures, nail trauma and finger sucking. When it is necessary to wear vinyl gloves, cotton gloves should be worn underneath.
The affected area should be kept dry, and moisturizers should be applied after washing hands. Rubber gloves should be used, preferably with inner cotton glove or cotton liners while performing any work with probable exposure to irritants.Further injury may be minimized by keeping the nails short and avoiding any manipulation of the nail, such as manicuring, finger sucking, or self attempt to incise and drain the lesion. The footwear should be properly chosen to avoid unnecessary damage to the nail.
Preventive measures are always the main part of therapy. The conventional mode of treatment is applied with Topical steroids have a major role to play in therapy than systemic anti-fungals .Treatment of potential secondary bacterial infections with antibacterial solutions or ointments, acetic acid soaks (1:1 ratio of vinegar to water) or oral antibiotics are also used. Surgical intervention like eponychial marsupialization technique, as well as removal of the entire nail and application of an antifungalsteroid ointment to the nail bed. is indicated when medical treatment fails1. These techniques are painful with adverse drug effects , with relapse of infection again and again .
The Homoeopathic Lancet talks about use of Myristica Sebifera which helps to matures abscesses, hastens suppuration and shortens its duration and builds an outlet for the drainage. It has acted very well even in cases where penicillin did not help at all. After drainage is established, there come in Hepar and Silicea to hasten the process of healing. Hepar sulph is required in cases where pus is thick, yellow and the patient is very sensitive and the touch of wound excites the pain. Silicea is applicable in cases where the patient is chilly and the discharge is thin and white. Both Hepar sulph, and Silicea are to be given in 200c potency. Myristica acts well in D3 (3x) and D6 (6x), given every 4 hours.
Here is a case described of patient suffering with Chronic paronychia with improvement in the quality of life of patient and no further recurrences
A 45yr old female belonging to a agricultural family from the village Karguppi , Belagavi complained of pain underneath the thumbnail and blackish discoloration in the borders and corners of nails of other fingers. She gives a history of trauma in the thumb while cutting the fodder for cattle. Patient says she started getting collection of pus and recurrent abscess below the thumbnail since the trauma . But before all these complaints she had blackish discoloration in the nail borders of all other fingers since past two years. She narrates that they grow flowers and vegetables in their farm so while processing the soil she mix the soil & fertilizer with bare hands, since then the dicolouration has started in the nails.
For the recurrent subungal abscess she would go to a local doctor and was treated with oral antibiotics which gave some relief and a new nail would appear but within few days again there was collection of pus with intense pain.
At present she c/o Burning and throbbing pain with collection of yellowish pus underneath the thumbnail with sensitivity to touch .she was given Hepar Sulph 200 3powders as pathological specific prescription . After prescribing Hepar sulph there was good healing seen in the nail , but again there was a relapse of c/o subungal abscess after 3 months so the case was reconsidered.
Now patient gives H/O Sense of formication underneath the nails Pain gets agg at night & touch Amel by rubbing gently.
O/E – Swelling with redness seen around the nailbed. Blackening of the nail in the edges with severe pain sensitiveness to touch. The nail gets removed on its own after every 4 months, with a new nail appearing. But the patient is in severe pain till she gets rid of the nail. Patient is highly restless moving from one place to another, do not sit in one place , Physical restlessness.
Totality of symptoms
- Sense of formication underneath the nails
- Burning type of pain under the nails
- Recurrence of subungal abcess
Tarentula Cubensis 200/ 2 doses given on 1/10/15
1st Followup – 29/10/16
no tingling and numbness seen. Darkening underneath the nail bed is better than before
Treatment – Pl given for 1 month
Dictionary of Practical Materia Medica J. H. Clarke talks about the Tarentula Cubensis – Painful abscess ending by mortification of the integuments over it, and having several small openings discharging a thick,sanous matter containing pieces of mortified cellular tissue, fascia and tendon.
Materia Medica by W Boriecke – A Toxaemic medicine, septic conditions. Feels puffed all over Carbuncle, burning stinging pains.Abscesses where pain and inflammation predominate.
Hence Tarentula Cubensis can be considered as remedy indicated in treating Paronychia and also subungal abcessess by considering the above case as clinical proving.
List of References
- Dimitris Rigopoulos, Stamatis Gregoriou , George Larios, American family physician, , Acute and chronic paronychia , March 2008 Source: PubMed https://www.researchgate.net/publication/5554216
- P G Rockwell, Acute and Chronic Paronychia Am Fam Physician 63 (6), 1113-6 2001 Mar 15
- Vineet Relhan, Khushbu Goel, Shikha Bansal, and Vijay Kumar Garg, Management of Chronic Paronychia Indian J Dermatol. 2014 Jan-Feb; 59(1): 15–20. doi: 10.4103/0019-5154.123482
- Dr. Manisha Bhatia, Paronychia – Homeopathy Treatment and Homeopathic Remedies August 11, 2008
- Madeleine Innocent Paronychia and Its Rapid Resolution Using Homeopathy December 08, 2009
- Lily Samardzic-Rafik, Acute Paronychia , June 18, 2015
- Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 3d ed. St. Louis: Mosby, 1996.
- Hochman LG. Paronychia: more than just an abscess. Int J Dermatol 1995;34:385-6.
- Rich P. Nail disorders. Diagnosis and treatment of infectious, inflammatory, and neoplastic nail conditions. Med Clin North Am 1998;82:1171-83,vii.
- Bednar MS, Lane LB. Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia. J Hand Surg Am. 1991;16:314–7. [PubMed] [Google Scholar
- Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008;77:339–48. [PubMed] [Google Scholar]
- Team Homeopathy 360, Myristica Sebifera: The Homoeopathic Lancet January 21, 2017
Dr Shweta B Nanjannavar MD (Hom)
Asso Prof, Practice of Medicine
A M Shaikh Homoeopathic Medical College , Belagavi, Karnataka