Skin Diseases - Nail Infection

Nail Infection

Fungal Infection (Onychomycosis)

What do you see?

Onychomycosis may affect one or more toenails and/or fingernails and most often involves the great toenail or the little toenail. It can present in one or several different patterns.

Seen as whitish to yellow brown discolouration of nails or splitting of nails, can be associated with pain in nail folds.


Clippings can be taken from crumbling tissue at the end of the infected nail. The discoloured surface of the nailscan be scraped off. The debris can be scooped out from under the nail.

Previous treatment can reduce the chance of growing the fungus successfully in culture so it is best to take the clippings before any treatment is commenced.

A nail biopsy may also reveal characteristic histopathological features of onychomycosis.


Fingernail infections are usually cured more quickly and effectively than toenail infections.

Mild infections affecting less than 50% of one or two nails may respond to topical antifungal medications but cure usually requires an oral antifungal medication for several months.

Combined topical and oral treatment is probably the most effective regime.

Devices used to treat onychomycosis:

Recently, non-drug treatment has been developed to treat onychomycosis thus avoiding the side effects and risks of oral antifungal drugs.

  • Nd:YAG continuous, long or short-pulsed lasers.


What is Paronychia?

Paronychia is inflammation of the skin around a finger or toenail.

It can be acute (> 6 weeks) or chronic (persisting > 6 weeks).

Acute Paronychia can follow a break in the skin, especially between the proximal nail fold/cuticle and the nail plate. For example:

  • If the nail is bitten, infants that suck their fingers or thumbs.
  • Following manicuring.
  • Ingrown toenails.
  • On application of sculptured or artificial fingernails.

Chronic Paronychia mainly occurs in people with hand dermatitis, or who have constantly cold and wet hands, such as:

  • Dairy farmers.
  • Cleaners.
  • Housewives.
  • People with poor circulation.

What causes paronychia?

Acute paronychia is usually due to bacterial infection (e.g.Staphylococcus aureus),can also be caused by virus, (e.g. Herpes simplex), and the yeast, (e.g. Candida albicans).

Chronic paronychia can be caused due to dermatitis of the nail fold. Often several different micro-organisms can be cultured together in this condition.

What do you see?

Acute paronychia develops rapidly over a few hours, and usually affects a single nail fold. Symptoms are pain, redness and swelling. Can be associated with fluid filled lesions, collection of pus, and fever.

Chronic paronychia is a gradual process. It may start in one nail fold, particularly the proximal nail fold, but often spreads laterally and to several other fingers. Each affected nail fold is swollen and lifted off the nail plate. This allows entry of organisms and irritants.The affected skin may be red and tender from time to time, and sometimes a little pus (white, yellow or green) can be expressed from under the cuticle.


Paronychia is a clinical diagnosis, often supported by laboratory evidence of infection.

  • Gram stain microscopy- bacteria.
  • Potassium hydroxide - fungi.
  • Bacterial culture.
  • Viral swabs.
  • Tzanck smears.
  • Nail clippings for culture (mycology).


Acute Paronychia:

  • Soak affected digit in warm water, several times daily.
  • Topical antiseptic.
  • Oral antibiotics.
  • Anti-viral treatment.
  • Surgical incision and drainage may be required for abscess.
  • Nail might be removed to allow pus to drain.

Chronic Paronychia:

Attend to predisposing factors.

  • Keep the hands dry and warm.
  • Avoid wet work, or use totally waterproof gloves that are lined with cotton.
  • Keep fingernails scrupulously clean.
  • Wash after dirty work with soap and water, rinse off and dry carefully.
  • Apply emollient hand cream frequently.
  • Topical corticosteroid or immunomodulatory drugs.
  • Intralesional injections - Resistant cases.
  • Oral antifungal agents.

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