Paronychia (nail fold infection): symptoms, causes and treatment

Treatment depends on whether the paronychia is acute (sudden and painful) or chronic (long-running), and how severe it is. The Primary Care Dermatology Society (PCDS) guidance for GPs sets out the following steps.

For an early, mild acute infection the guidance is to soak the affected digit in warm water several times daily. The NHS ingrown toenail page describes soaking the foot in warm, salty water to soften the skin around the toe and reduce the chance of infection, then keeping the foot dry for the rest of the day, wearing wide, comfortable shoes or sandals and taking paracetamol or ibuprofen to ease pain.

Whether you have paronychia or not, the NHS nail advice applies. Wear rubber gloves if your hands are often in water or you use cleaning products regularly, apply hand cream to your nails and fingertips, and do not bite or pick your nails or the skin around them.

• Do not squeeze or lance a swollen nail fold yourself.

• Avoid pushing back or cutting the cuticle, and avoid manicures while the skin is inflamed. PCDS advises avoiding any manipulation of the nail such as manicuring.

• Do not clean under your nails with sharp objects, as the NHS advises.

• For toes, cut straight across the top of the nail rather than down the edges, and do not wear shoes that pinch.

• A pharmacist can advise about treatments to ease pain and prevent infection of an ingrown toenail and whether you need to see a GP.

The PCDS describes acute paronychia as a tender swelling, most commonly of the side of the nail, with redness (erythema) and sometimes a pustule that can occasionally evolve into an abscess. It mainly affects children and adolescents in that guidance. The NHS lists skin around the nails that has become sore, red, swollen and warm as paronychia, which can be a sign of infection or an ingrown toenail.

Chronic paronychia is an inflammatory skin condition of the nail folds. It begins as a slight red swelling of the nail folds, the cuticle is lost and pus may collect beneath the fold. Although uncomfortable, PCDS says it is generally less painful than acute paronychia.

Repeated flare-ups can affect the nail matrix, the area where the nail grows. PCDS says this can lead to numerous irregular transverse ridges, a discoloured nail and, in longstanding cases, a nail that reduces in size.

The two forms behave differently, and recognising which one you have changes what helps.

Infection needs an entry point. PCDS says organisms enter through a break in the epidermis resulting from trauma to a nail fold, loss of the cuticle, or chronic irritation, for example from water and detergents. Biting or sucking fingers can also predispose to infection. In toes, infection often begins in an ingrown toenail.

The organisms are usually Staphylococcus aureus or streptococci and, less commonly, pseudomonas or proteus species. Occasionally the infection is viral, from herpes simplex virus (a herpetic whitlow, which presents as grouped small blisters and can recur) or orf virus.

Chronic paronychia is predominantly a disease of people whose work involves water or chemicals, and handling wet foods is a particular hazard because wet conditions, cold and irritation from the food combine. Other causes include an underlying inflammatory skin condition such as atopic eczema or psoriasis, and finger or thumb sucking in children. Yeast infections such as candida can be associated.

Chronic paronychia is managed mainly by dealing with the factors that keep it going. PCDS advises avoiding manipulation of the nail, avoiding finger sucking and wearing rubber or plastic gloves for wet work, preferably with inner cotton gloves or cotton liners. It recommends avoiding soaps and detergents in favour of a soap substitute and applying emollient creams regularly.

For flare-ups, topical treatments may include antifungal lotions or drops, or a combined steroid, antiseptic and antifungal cream, and occasionally a more potent topical steroid for a short time if inflammation is marked. In more troublesome cases where a swab confirms candida, a short course of an oral antifungal medicine may be required.

Swabs can be sent for culture and sensitivity, and occasionally for viral testing if herpes simplex is suspected.

An ingrown toenail is a nail growing into the surrounding skin, while paronychia is infection or inflammation of the nail fold. One can lead to the other. The NHS says an ingrown toenail may be red, painful and swollen, and signs of an infected toe include pus coming out of it and feeling hot or shivery.

A GP can check for an ingrown toenail and give antibiotics if it is infected. A badly ingrown toenail may be referred to a podiatrist, who may cut away part of the nail or remove the whole nail, usually with a local anaesthetic injection. NHS podiatry may not be available to everyone and waiting times can be long, and in some areas you can refer yourself directly. Ask your GP surgery or integrated care board.

The NHS says to see a GP if you have diabetes and an ingrown toenail, because foot problems can be more serious if you have diabetes.

The NHS advises seeing a GP if the skin around your nails has become sore, red, swollen and warm, or if a nail has changed shape, changed colour or fallen off and you do not know why. Seek help sooner if pus is collecting, treating it at home is not helping, or you have a very high temperature or feel hot, cold or shivery.

The NHS cellulitis page says to ask for an urgent GP appointment or get help from NHS 111 if your skin is painful, hot and swollen, because early antibiotics can stop cellulitis becoming more serious. Cellulitis in the hand can cause swelling of the fingers or the back of the hand.

The NHS says to call 999 or go to A&E if you have cellulitis with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, dizziness or fainting, confusion, cold, clammy or pale skin, or unresponsiveness. Do not drive yourself to A&E.

Because the trigger is usually a break in the skin or constant wetness, prevention focuses on protecting the nail folds. The NHS nail page and PCDS guidance suggest the same measures.

• Wear waterproof gloves with cotton liners for wet work and cleaning.

• Dry your hands thoroughly and moisturise your nails and fingertips regularly.

• Do not bite, pick or suck nails and fingers.

• Do not cut toenails down the sides, and keep them from being too short.

• Do not ignore fungal skin infections such as athlete’s foot, as the NHS advises, and ask for help with eczema or psoriasis affecting the hands, which PCDS lists as an underlying cause.

On the NHS the usual route is a GP, and the NHS says you may be able to refer yourself directly to a podiatrist for nail problems, depending on local services. A pharmacist can also advise on ingrown toenail pain. The NHS says you can pay to see a podiatrist privately.

Wherever you are seen, a swab can be sent if the infection is not settling, so mention how long the problem has lasted, what you have already tried and whether you do wet work or have diabetes.