An incisive approach to chronic paronychia: The square flap technique
By Warren R. Heymann, MDAug. 2, 2016
I cannot begin to guess how many patients I have seen with chronic paronychia (CP) since I started my residency 36 years ago. I know precisely how many patients I have referred for surgical correction of CP — zero! The reason for that is that I never thought about this condition being amenable to surgery. How ignorant I have been!
According to Shafritz and Coppage (1):
Chronic paronychia is inflammation of the perionychium that has been present for >6 weeks. This inflammation can have many causes and often is related to repeated exposure to environmental irritants, with colonization by fungal or bacterial pathogens that occurs after disruption of the barrier formed by the eponychium and nail vest. Exposure to irritants can take many forms and persons with a higher risk of chronic paronychia include those with frequent exposure to moisture and/or chemical irritants. Homemakers, bartenders, barbers, dishwashers, cooks, food handlers, swimmers, and nurses are commonly identified as having an increased risk of chronic paronychia. Conditions such as diabetes mellitus and immunosuppression also predispose patients to development of chronic paronychia.
Standard medical therapy for chronic paronychia includes avoiding wet work, trauma, and irritants. The pharmacologic approach focuses on decreasing infection (bacterial, and or fungal, typically Candida) by antibiotics and antifungal treatment, and decreasing inflammation by the use of topical steroids and/or calcineurin inhibitors. If there is no response to medical therapy, a surgical approach may be warranted. Previous techniques included removing the proximal nail fold leaving the nail intact or by performing an en bloc removal of the nail fold.
Ferreira Viera d’Almeida et al described the “Square Flap” technique for chronic paronychia. Under local anesthesia, oblique incisions are made on the nail fold, making a flap. The fibrotic tissue responsible for the chronic paronychia is excised and the cuticle is then resutured. I suggest that you watch the video to fully appreciate this surgical technique. I was astounded by the degree of fibrosis that is responsible for the problem. After watching the video, I fully comprehend why most of my patients did not improve — the extent of subungal fibrosis explains why standard medical therapy is unlikely to alleviate the condition. The authors treated 34 fingers with CP (from 9 patients); 32 of the 34 fingers improved with maintenance of nail plate length. A disadvantage of the procedure is that it is “neither fast nor easy to perform, requiring a skilled nail surgeon’” (i.e., not me). Complete healing occurs in 2 weeks and cuticle regrowth in 6 weeks, allowing the patient to return to daily activities (2).
I was a third year medical student on my surgical rotation when I first heard the adage “A chance to cut is a chance to cure.” Even for chronic paronychia!
1. Shafritz AB, Coppage JM. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg 2014; 22: 165-74.
2. Ferreira Viera d’Almeida L, et al. Chronic paronychia treatment: Square flap technique. J Am Acad Dermatol 2016; 75: 398-403.
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