SURGICAL TREATMENT OF CHRONIC PARONYCHIA: A COMPARATIVE STUDY OF 138 SURGERIES USING TWO DIFFERENT TECHNIQUES

Received on 12/02/2009
Approved on 25/02/2009
We declare no conflict of interest.

Abstract

Introduction: Chronic paronychia is an inflammatory disorder of the proximal nail fold (PNF) lasting more than six weeks that accounts for 18% of nail dystrophies. Clinically, it is characterized by inflammation of the PNF, absence of the cuticle, and dystrophy of the nail plate. Clinical treatment is usually unsatisfactory. Surgical treatment consists on the removal of the PNF, which can be done using the oblique or perpendicular incision techniques.
Objective: The objective of the present study was to compare the efficacy of oblique and perpendicular surgical techniques in the treatment of chronic paronychia.
Methods: Sixty-two patients with chronic paronychia, in one or more fingers (with a total of 138 surgeries), were randomly divided into two groups, according to the surgical technique used (perpendicular or oblique incision). Postoperative evaluation was done after six months using a three-point scale: absence of improvement, improved, cured.
Results: One hundred and thirty-four cases (97.1%) were considered cured, and 4 (2.9%), two in each group, were considered as having improved.

INTRODUCTION AND OBJECTIVE

Chronic paronychia is considered an inflammatory disease with a duration longer than six weeks, affecting one or more nail folds (lateral and/or proximal).¹ It affects females more than males, and accounts for 18% of nail dystrophies.²

The clinical presentation is characteristic, with inflammation of the proximal nail fold (PNF), absence of cuticle, and dystrophy of the nail plate.^3,4

Clinical treatment consists in avoiding predisposing factors and using topical and/or systemic drugs; however, results are usually unsatisfactory.^5,6

Surgical treatment (aiming at removing the proximal nail fold) is indicated in cases resistant to clinical treatment.³ Two surgical techniques have been described, and they differ in the direction of the incision and amount of PNF removed.^7,8

Based on those data, we proposed a randomized study comparing the efficacy of both surgical techniques.

PATIENTS AND METHODS

From November 2004 to April 2008, 72 patients were seen at the Dermatology Outpatient Clinic of the Hospital do Servidor Público Municipal de São Paulo with the diagnosis of chronic paronychia. Parameters evaluated included gender, age, professional activity, and finger affected. Inclusion criteria were as follows: duration of the disease (more than two years), no response to clinical treatment, and no use of specific topical or systemic drugs for at least two months. Exclusion criteria included: pregnancy, diabetes, peripheral vascular insufficiency, collagen disease, and use of systemic drugs that could interfere with coagulation. In total, 10 patients were excluded, and 62 patients underwent surgery in one or more fingers, with a total of 138 procedures.

Two surgical techniques, differing in the type of incision, were used to remove the PNF. In the first technique (Figure 1), the incision is performed in a perpendicular angle to the skin, removing completely the PNF; in the second, the incision is oblique and the upper PNF is removed, leaving its lower portion (Figure 2).

After appropriate cleaning of the area, the finger was anesthetized with 2% lidocaine without vasoconstrictor and a tourniquet was applied. The proximal nail fold was removed using one of the two techniques. The tourniquet was removed and a compressive dressing with rayon gauze and cotton was placed after the surgery.

Patients were instructed regarding the use of analgesics and to return on the first postoperative day to remove the dressing. The wound was washed with NS (normal saline), followed by the use of an antibiotic cream, and placement of a new dressing. The dressing was changed daily until complete healing of the surgical wound.

Patients were instructed to return on the 1st, 10th, 60th, and 180th postoperative days.

Photographs of the lesions were taken on the first consultation, and 10 and 180 days after the surgery.

To evaluate the results of the surgeries, photographs taken before and after the treatment were analyzed by one of the authors and a dermatologist not involved in the study, according to a scale with three options: absence of improvement, improved, and cured.

Categorical parameters are shown as frequencies and percentages, while continuous parameters are presented as means.

RESULTS

Out of 62 patients, 50 were females (80.65%) and 12 were males (19.35%), with a proportion of 4 women for each man. The age of the subjects varied from 29 to 74 years, with a mean of 52 years.

The fingers involved more often were: 3rd (27.5%), 1st (26.8%), 4th (23.9%), and 5th (5.8%). In 28 patients (45.1%), only one finger was affected.

The occupational activity of the patients included: janitors (29.0%); housewives (20.9%); kitchen aid (14.5%); nurses’ aid (14.5%); and others (20.9%).

The oblique incision was used in 69 (50%) surgeries, and the perpendicular technique was used in the remaining 69 cases (50%).

Healing time varied from 6 to 14 days, with a mean of 10 days.

The evaluation of the author and of the independent dermatologist was similar in all cases. Out of 138 cases, 134 (97.1%) were considered cured (Figure 3). Four cases (2.9%), two in each group, were considered as showing improvements.

Statistical tests were not applied since the percentages were identical in both groups.

DISCUSSION

In the past, chronic paronychia was considered a fungal disease but with more recent studies that allowed better understanding of its pathogenesis and more efficient treatment approaches, it is currently classified as an inflammatory disorder of the nail complex.^6,9,10,11

Recurring traumas caused by aggressive manicures, frequent contact with alkaline water, and exposure to chemical agents cause changes and disappearance of the cuticle, resulting in a space between the proximal nail fold and the nail plate. This space is a port of entry for microorganisms, allergens, and primary irritating agents that cause the inflammatory process. Dermatological disorders (psoriasis and lichen planus), systemic disorders (leukemia and leprosy), and drugs (retinoids) can affect the nail fold, and are also considered possible etiological agents.^4,5

Therefore, the inflammatory process is the basis of chronic paronychia and infections are considered secondary events.

The age of the 62 individuals varied from 29 to 74 years, with a mean of 52 years, and the study population had a proportion of 4 women for each man; those data are similar to those found in the literature.¹²

Professional activities more frequent among our patients involved frequent water manipulation. This corroborates the theory of damage to the cuticle and formation of a space between the nail fold and nail plate, favoring the entry of pathological agents and maintenance of the inflammatory process.⁴

Unlike the data found in the literature in which the incidence of this affection is higher in the 2nd fingernail, in our study the 1st, 3rd, and 4th fingernails had similar incidence of paronychia, but it was lower in the 2nd and 5th fingernails.³

A few surgical techniques have been described for this pathology. In 1981, Baran and Burean described the technique of block removal of the proximal nail fold, which was referred to in the present study as “technique with perpendicular incision of the PNF”, because we consider this description more complete.⁷

Keyser and Eaton (1976) described the technique of eponychial marsupialization, which consists in the removal of the dorsal surface of the proximal nail fold, maintaining the ventral portion, without removing the nail plate. We prefer to call this a “technique with oblique incision of the PNF” 8 (Figure 2).

Some authors proposed a modification of those techniques, associating the removal of the nail plate.^3,13

In our study, the techniques of perpendicular and oblique incision of the PNB were compared. The nail was not removed because the authors do not agree with this procedure. We observed that the dystrophic nail is substituted by a normal nail plate as the nail grows. Besides increasing the length of the surgery, removal of the nail plate facilitates the occurrence of unnecessary dystrophies of the nail plate.¹⁴

All cases presented a fast healing, with a mean period of 10 days. We could observe that, in the second postoperative month, the cuticle had regenerated, assuming its role of protecting the PNF.

Out of the 69 cases of perpendicular incision, 67 (97.1%) were considered cured and two (2.9%) showed improvement. The same results were observed with the oblique incision.

CONCLUSION

Based in our results, we concluded that both techniques (perpendicular and oblique incision) for surgical treatment were effective in the treatment of chronic paronychia.

Conclusion: In the present study, we concluded that the surgical treatment of chronic paronychia is effective, regardless of the technique used.

References

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