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Common Nail Disorders

1. Paronychia
1. Paronychia are inflammatory swellings around the nail bed, usually involving the lateral and posterior nail folds.
2. They usually are the result of trauma, nail picking/biting, and breakdown of the normal skin barriers secondary to chronic moisture exposure or thumb sucking.
3. This condition presents with pain of the distal phalaynx, followed by redness, warmth, tenderness, and swelling. There may be a thin line of pus visible under the skin around the nail edge.
4. Common identified infectious agents of acute paronychia are Staphylococcus aureus, herpes simplex virus (HSV), and Streptococcus pyogenes. Less common are Gram-negative organisms (Pseudomonas, Proteus). Chronic paronychia is most commonly caused by yeasts (i.e. Candida albicans).
5. Soft-tissue changes in acute paronychia may lead to onycholysis, Beau's lines or onychomadesis. Distal phalanx also may be involved by impetigo.
6. Treatment
1. Soak in warm water to promote drainage. This will be successful in the majority of the cases.
2. May require I&D with scalpel.
3. If there is development of cellulitis or it starts spreading, treatment with Keflex or Augmentin by mouth is recommended.
4. If neglected, it may spread under the nailbed and lead to the loss of the nail.

2. Ingrown Nails
1. Normal nail or fragments penetrate the nail edge.
2. Results from improper fitting shoes, picking at the nails, and improper cutting techniques. Nails should be trimmed when the nail grows out beyond the nail edge and should be cut straight across.
3. Infants will often have some erythema around their toenails, but if not tender it should be left alone.
4. Most common in older children ad adolescents. It usually involves the medial or lateral side of the large toes. The child presents with a very painful, red, swollen area around the nail edge. There may be some purulent or serosanguinous discharge, as well as granulomatous tissue.
5. Treatment
1. In early cases, the nail may be lifted after soaking and a piece of cotton placed under the nail. Proper cutting techniques and shoe fitting should be emphasized.
2. In more advanced cases, the nail and granulation tissue need to be trimmed. The nail bed area is injected with a local anesthetic and the nail is trimmed and removed from under the penetrated tissue.
3. In recurrent cases, the patient may need definitive surgery with removal of the nail matrix. A referral to an orthopedic surgeon or podiatrist is indicated.

3.     Subungal Hematoma

a.      The presence of a hematoma under the nail bed is common after trauma, getting the finger caught in a door, or being smashed by dropping an object on the extremity. It is occasionally associated with a fracture.

b.     Presents with an obvious collection of blood under the nail. It is tender and throbbing.

c.      Treatment

i.      Evacuation of the blood by "drilling" a hole in the middle of the nail.