Diagnosis of Paronychia
Paronychia Diagnosis: Book Excerpts
Diagnostic Tests for Paronychia: Online Medical Books
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NAIL ABNORMALITIES:
Ask the Following Question:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are the abnormalities focal or diffuse? Focal abnormalities include thickening, which is often due to fungus infections; inflammation, which is usually due to a paronychia, onychia, fungal infection, or syphilis; hemorrhages under the nail, which may be due to trauma, subacute bacterial endocarditis, or trichinosis; pitting of the nail, which may be due to psoriasis; and atrophy or dystrophy of the nail, which may be due to peripheral vascular disease, epidermolysis bullosa, nail biting, peripheral neuropathy, and various other dermatoses. Diffuse abnormalities of the nail may include thickening due to syphilis, hyperthyroidism or hypothyroidism, clubbing, cyanotic heart disease, bronchiectasis, carcinoma of the lungs, and other disorders; yellow nails due to lymphedema or chest conditions; and spoon nails due to iron deficiency anemia.
- Diffuse spoon nails may be caused by iron deficiency anemia. Yellow nails may be due to lymphedema or chest conditions. Clubbing may be due to cyanotic heart disease, bronchiectasis, or carcinoma of the lung
. Thickening may result from syphilis, hyperthyroidism, or hypothyroidism. Hemorrhages may be due to trauma, subacute bacterial endocarditis, or trichinosis. Pitting may be due to psoriasis. Focal thickening may be due to fungus infections. Focal inflammation may be due to paronychia, onychia, or syphilis. Focal atrophy or dystrophy may be due to peripheral vascular disease, peripheral neuropathy, epidermolysis bullosa, nail biting, or other dermatoses.
DIAGNOSTIC WORKUP
Focal abnormalities of one nail warrant a culture and sensitivity of any scrapings or exudates from the area, as well as an x-ray of the digit or extremity. A CBC and sedimentation rate will help identify an infectious process. A glucose tolerance test will help identify diabetes mellitus. Careful assessment of the area for vascular insufficiency includes Doppler studies and possibly arteriography. A nerve conduction velocity study and EMG may be necessary if peripheral neuropathy is suspected. A skin or nail biopsy may be helpful.
Routine tests for diffuse nail changes include a CBC, sedimentation rate, chemistry panel, VDRL test, ANA, thyroid profile, chest x-ray, and EKG. Arterial blood gases and pulmonary function studies should be done if clubbing is suspected. Other tests for clubbing will be found on
page 82
. Serial blood cultures should be done if subacute bacterial endocarditis is suspected.
Trichinella
skin test or antibody titer should be done in cases in which there are splintered nails with negative cultures for subacute bacterial endocarditis. Muscle or skin biopsy will be useful not only for trichinosis but also for collagen disease. Nerve conduction velocity studies and EMGs will be helpful in diagnosing peripheral neuropathy.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Nail Disorders:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Onychomycosis
–Very common cause of nail thickening,
yellowing, and subungual debris
–Due to a dermatophyte infection
–May affect one or all fingers and toenails
–Patients often have coexisting tinea pedis or
tinea manum
- Psoriasis
–More than 50% of patients with psoriasis have associated nail changes, including pits, “oil spots,” and onycholysis
–Distinguishing nail fungus from psoriasis can be very difficult on clinical exam
–Most patients with nail disease have some other skin manifestation of psoriasis (plaques of thick, silvery white, adherent scalp scale that overlies well-demarcated patches of erythema)
- Paronychia
–Tenderness, erythema, and peeling around
the nail
–Very common and exquisitely painful
–Often exacerbated by “wet-work” (e.g.,
dishwasher)
–May have bacterial and/or yeast (candida)
component
–Occurs after minor cuticular trauma
–Can cause nail dystrophy without treatment
- Nail trauma
–Very common, especially great toenails and
thumbnails
–Easily misdiagnosed as fungal disease
–Can cause separation of the nail from the
nail plate
-
Malignancy (e.g., subungual melanoma, squamous cell carcinoma)
-
Endocrine disease (e.g., hyper- and hypothyroidism) can cause splitting, drying, and other nail changes
-
Lichen planus and atopic eczema can affect the nail matrix and lead to nail dystrophy
-
Alopecia areata (patchy autoimmune hair loss) can be associated with nail pits as well
-
Several congenital disorders (e.g., ectodermal dysplasia) can cause nail dystrophy in association with other skin and systemic disorders
-
Spoon-shaped nails may indicate iron deficiency
Workup and Diagnosis
-
History and physical examination
–Personal or family history of psoriasis
–Full skin exam to assess for skin disease
–Ask about the patient's work and hobbies
-
Onychomycosis (nail fungus) is diagnosed by clipping the affected nail and curetting subungual debris for PAS (fungal stain) and/or culture
–PAS stain is less expensive and quicker than culture
–Cultures are more helpful when a patient is refractory to systemic therapy; certain nondermatophytes (e.g., Aspergillus, Fusarium) can act as nail pathogens and are difficult to eradicate with some antifungal drugs
-
Paronychia requires incision and drainage for fungal and bacterial cultures to determine the appropriate topical or systemic treatment and to relieve pain
-
Nail matrix biopsy is unnecessary unless a tumor may be the cause of a persistent, isolated, single nail dystrophy or deeply pigmented longitudinal band (>3 mm)
-
Referral to dermatology is indicated in unusual, recalcitrant, or potentially malignant cases
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
NAIL CHANGES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The diagnosis of nail abnormalities begins by correlating the nail changes with other findings (e.g., neurologic and endocrinologic). Laboratory workup depends on the particular disease or diseases suggested by the nail changes (see Appendix).
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Source: Differential Diagnosis in Primary Care, 2007
PALLOR OF THE FACE, NAILS, OR CONJUNCTIVA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of pallor is obviously to check for anemia first; then examination for the other chronic disorders may be carried out. Chest x-ray, ECG, sedimentation rate, and a check for rheumatoid factor are all appropriate in specific cases.
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Source: Differential Diagnosis in Primary Care, 2007
Nail Phenomena/Clubbing:
Differential Overview
(Field Guide to Bedside Diagnosis)
Phenomena
❑ Pitting
❑ Transverse depression
❑ Transverse white line
❑ Nailfold telangiectasias
❑ Nailfold infarcts
❑ Splinter hemorrhages
❑ Onycholysis
❑ Spoon nails
❑ Blue-green nails
❑ White nails
❑ Half-and-half nails
❑ Yellow nails
❑ Blue lunulae
❑ Red lunulae
❑ Black longitudinal streak
Clubbing
❑ Bronchogenic cancer
❑ Tuberculosis
❑ Endocarditis
❑ Inflammatory bowel disease
❑ Familial
❑ Trauma
❑ Grave disease
❑ Cirrhosis
❑ Cystic fibrosis
❑ Cyanotic congenital heart disease
❑ Pulmonary fibrosis
❑ Mediastinal Hodgkin disease
❑ Mesothelioma
❑ Lung abscess
❑ Bronchiectasis
❑ Hypertrophic osteoarthropathy
❑ Pachydermoperiostosis
Diagnostic Approach
Nails contain an archive of information about physiologic conditions affecting their growth, similar to the way tree rings record the weather of summers past. If examined closely, they may also contain the subtlest of clues to important
systemic illness, such as endocarditis.
Clubbing is most sensitively detected by loss of the normal nail angle when seen in profile, or by putting corresponding fingers back to back and looking for loss of the diamond of light. Springiness or ballotability of the base of the nail is another early sign. The overlying skin is smooth and shiny, and the nailbeds are cyanotic. Nails of patients with chronic paronychia may be confused with clubbing.
When clubbing is present, specifically examine for findings of associated illness including peripheral stigmata of endocarditis, murmurs, splenomegaly, jaundice, wheezes, rales, pleural effusion, supraclavicular adenopathy, hepatomegaly, abdominal mass, thyromegaly, and ophthalmopathy.
Unilateral clubbing may be caused by impairment of the vascular supply to the arm. Causes include aortic or subclavian artery aneurysm, anomalous aortic arch, pulmonary hypertension with patent ductus arteriosus, brachial arteriovenous fistula, superior sulcus lung tumor, and recurrent shoulder dislocation. Unidigital clubbing may be caused by median nerve injury or sarcoidosis. Clubbing of toes without fingers can be seen in coarctation of the aorta.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
NAIL CHANGES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The diagnosis of nail abnormalities begins by correlating the nail
changes with other findings (e.g., neurologic and endocrinologic).
Laboratory workup depends on the particular disease or diseases suggested by
the nail changes (see Appendix A).
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
PALLOR OF THE FACE, NAILS, OR CONJUNCTIVA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of pallor is obviously to check for
anemia first; then to examine for the other chronic disorders. Chest x-ray,
electrocardiogram (ECG), sedimentation
rate, and a check for rheumatoid factor are all appropriate in specific
cases.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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