Case of the Month with Crutchfield Dermatology

Friday, January 3, 2014

A day after a 22-year-old woman moved boxes in her garage, her finger is tender. She states that while moving boxes, “the edge of one of the boxes struck and pushed the edge of my skin hard where it meets the nail. It hurt for about 15 minutes and then went away. The next day when I woke up, it was very painful and looked like this.” (She texted in a picture with her smartphone.)
She was otherwise healthy and taking only a multivitamin and OCPs.

Diagnosis: Dermatitis Herpetiformis, (Acute) Paronychia

Paronychia is an inflammation of the skin around a nail. It is usually characterized as either acute or chronic. More often than not, it affects fingernails, but it can also affect toenails. Both types of paronychia usually involve infections. Acute paronychia is extremely tender and often caused by bacteria that are introduced secondarily to trauma, as in this case in which the corner of a moving box injured the nail fold. Other common causes of trauma include aggressive manicures, nail-biting, hang-nail removal, ingrown nails, splinters/foreign bodies, and any extended use of hands in which nail fold trauma is a high probability. Chronic paronychia that involves inflammation and redness around the fingernail and that lasts more than four to six weeks is typically not painful and is often caused by fungus.

I find the most instructive investigation to use when a patient presents with paronychia is to ask if it hurts.

Although there is no strong supporting clinical research with regard to acute paronychia, in my experience, an antibiotic usually works well and resolves the problem. In this particular case, the patient was given a Z-pack and reported improvement in two days. Cephalexin and clindamycin are reported to work well, too. For chronic paronychia, often an oral antifungal medication is used in conjunction with a mild to moderate topical anti-inflammatory steroid (such as triancinalone ointment 0.1 percent), twice daily for five to seven days. Although there are many oral antifungal options, my treatment of choice is either terbinafine (Lamisil) 250 mg once daily for 30 days or a one-week pulse of itraconazole (Sporanox, two 200 mg tabs twice daily for seven days). For terbinafine, I do baseline complete blood count and liver function tests and repeat in seven to 10 days.

In cases of acute paronychia in which there is a pustule, the pustule should be drained before initiating antibiotic therapy, and warm water soaks should be instituted daily for the first few days.

For more information, contact Charles E. Crutchfield III, MD, at Crutchfield Dermatology or visit