Saturday, October 27, 2007

Paronychia in a Child

The patient is an eight year-old girl with a three week history of paronychial inflammation. Mild pain at onset and now. No history of trauma or finger sucking. She was first seen by her pediatrician around ten days after onset and told it was improving and to give it time. No improvement after ten days; given a ten day course of cephalexin and urged to do warm soaks. No improvement noted. Seen in Dermatology Clinic October 26, 2007.



































Examination: Marked inflammation of proximal and lateral nail folds. No fluctuance. Perhaps, mild pain. No discharge. KOH from chalky material at proximal nail fold negative. The entire nail is dystrophic, perhaps suggesting longer involvement,

Questions:
Is this an acute bacterial or a chronic candidal paronychia?
Should the proximal nail fold be explored?
Other than bacterial and fungal cultures, any further studies?
What would you do at this point?

6 comments:

  1. I think it is chronic candidal paronychia(the eponichion is absence-sign of candida paronychia).No improvement treatment with cephalexin, also make me think about chronic candidal paronychia.

    1.routine Gram staining helps in identifying the organism.
    2.Potassium hydroxide 5% smears may be helpful in diagnosing fluctuant paronychia if Gram staining results are negative or if candidal infection is suspected, as in chronic paronychia.

    As for treatment of chronic candidal paronychia i supposed 150mg DIFLUCAN® (fluconazole), one time a week for 3-4 months(min).

    ReplyDelete
  2. While I don't like using combination creams too often (means I don't know the cause ;), the possibilities include candida, bacterial staph or strep, and acrodermatitis continua of hallopeau, so I would use a combincation topical product to target all three possibilities.

    Ben

    ReplyDelete
  3. I agree this is a localised process - most likely an infective process. There is also evidence of onychomadesis ( nail shedding with the nail separated from the matrix.)this is a result of local acute infection. I suspect it is Staph/Strep more than fungal infection

    Wet soaks with dil. KMNO4 helps dry up the lesions.

    ReplyDelete
  4. Monica LawryNovember 01, 2007

    my comments were too lengthy for the blog...so I
    moved them here:

    The appropriate work up and treatment for acute
    bacterial paronychia has been done. The nail plate
    shows what looks like a Beau's line about 5mm from the
    proximal nail fold. The changes on the nail plate at
    the proximal nail fold suggest onychomadesis. The
    erythema of the entire digit tip, lack of pain and
    nail plate findings suggest a psoriatic process. This
    may evolve into more obvious pustular psoriasis at a
    later time. I would treat with potent topical
    steroids under occlusion. Trimming the nail short to
    prevent further trauma and perhaps Koebnerization is a
    good idea.

    Please let me know how she does. I'm also curious if
    there are any other findings on exam or family
    history.

    ReplyDelete
  5. Bhushan KumarNovember 01, 2007

    For the child with nail lesions it is an early case of acrodermatitis continua which is considered as a variant of psoriasis.

    ReplyDelete
  6. Dr. Merlina Joseph, MDNovember 02, 2007

    Perhaps an oral fungal should be given despite the fact that the KOH was negative. KOH may be negative but a fungal culture may be positive.

    ReplyDelete

We welcome your comments. We endeavor to serve your patients and you. If you want us to respond, please add your name and email address. Some people have trouble uploading comments. In that case, please send comments directly to djelpern@gmail.com. Thank you.