- Email: [email protected]
Clinical and cytologic features of antibiotic-resistant acute paronychia
Clinical and cytologic features of antibiotic-resistant acute paronychia Murat Durdu, MD,a and Vincenzo Ruocco, MDb Adana, Turkey, and Naples, Italy Background: Acute paronychia usually is treated as a bacterial infection, but antibiotic-resistant acute paronychia may be caused by other infectious and noninfectious problems. Objective: We sought to describe the clinical, etiologic, cytologic, and therapeutic features of antibioticresistant acute paronychia. Methods: A retrospective review of medical records and cytology was performed in 58 patients (age, 1 month-91 years; 36 children and adolescents [62%] and 22 adults [38%]) who had antibiotic-resistant acute paronychias. Results: Causes of paronychia included bacteria (25 patients [43%]), viruses (21 patients [36%]), fungi (5 patients [9%]), drugs (3 patients [5%]), pemphigus vulgaris (3 patients [5%]), and trauma (1 patient [2%]). Diagnostic cytologic findings were noted in 54 patients (93%); no diagnostic cytologic findings were present with drug-induced (3 patients) or traumatic (1 patient) paronychia. The most common predisposing factors were the habits of finger- or thumb-sucking (14 patients [24%]) and nail-biting (11 patients [19%]). Complications included id reaction with erythema multiforme in 3 patients (5%). Limitations: Limitations include retrospective study design from 1 treatment center. Conclusion: Antibiotic-resistant acute paronychia may be infectious or noninfectious. Cytologic examination with Tzanck smear may be useful diagnostically and may prevent unnecessary use of antibiotics and surgical drainage. ( J Am Acad Dermatol 2014;70:120-6.) Key words: diagnosis; erythema multiforme; fungus; herpes virus; infectious diseases; orf virus; pemphigus vulgaris; Tzanck smear.
cute paronychia usually is caused by infection, and bacteria are the most common causative organisms. In addition, herpes virus, orf virus, and some fungi can cause acute paronychia.1,2 However, acute paronychia usually is treated as a bacterial infection. Most (65%) herpetic paronychias are initially misdiagnosed as bacterial paronychia.3 Therefore, topical and systemic antibiotics frequently are prescribed and may be misused for several weeks. The unnecessary use of antibiotics may cause the development of antibiotic-resistant bacteria.4 Surgical drainage without antibiotic
A
therapy may be an acceptable treatment in most patients who have acute paronychia, but it is important to distinguish nonbacterial from bacterial paronychia; viral paronychia may be a self-limiting infection for which surgical treatment is not indicated.5 Cytology is a simple, rapid, reliable, and inexpensive diagnostic method that has been used for the diagnosis of various infectious and noninfectious cutaneous diseases.6-9 In our clinic, we have been performing the Tzanck smear regularly during the past 7 years for patients who could not be given a
From the Bas¸kent University Faculty of Medicine, Department of Dermatology, Adana Hospitala; and Department of Dermatology, Second University of Naples.b Funding sources: None. Conflicts of interest: None declared. Accepted for publication September 25, 2013. Reprints not available from the authors.
Correspondence to: Murat Durdu, MD, Bas¸kent University Faculty of Medicine, Department of Dermatology, Adana Hospital, Seyhan, 01130, Adana, Turkey. E-mail: [email protected]. 0190-9622/$36.00 Ó 2013 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2013.09.042
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Definitive diagnosis Diagnoses of herpetic paronychia, orf virus paronychia, fungal paronychia, and paronychia caused by pemphigus vulgaris were made by evaluating the cytologic features and laboratory findings, including bacterial and fungal cultures and direct immunofluorescence tests on the cytologic smears (Fig 1). When paronychia developed after the use of drugs and CAPSULE SUMMARY there were no diagnostic cytologic findings, the paroMETHODS Acute paronychia usually is treated as a nychia was diagnosed as Patients bacterial infection. drug induced. When paroThis study was conducted In 58 patients who had antibioticnychia developed after between February 2011 resistant acute paronychia, 33 patients trauma and there were no and February 2013 at the (57%) had nonbacterial causes; cytology diagnostic cytologic findings, Department of Dermatology, (Tzanck smear) showed diagnostic the paronychia was diagBas¸kent University Faculty of findings in 54 patients (93%). nosed as traumatic. Medicine, Adana Teaching In paronychia, cytology may improve and Medical Research diagnosis and prevent unnecessary Center, Adana, Turkey. We Treatment antibiotics and surgical drainage. retrospectively analyzed the Bacterial paronychia was medical records of all patients treated with antibiotics acwho had acute paronychia cording to the results of antibiotic susceptibility that was resistant to systemic antibiotic. The clinical testing. Fungal paronychia was treated initially with and cytologic findings were recorded. Patients were itraconazole (100 mg twice daily for 2 weeks) and excluded because of paronychia caused by an insubsequently according to antifungal susceptibility grown nail, chronic paronychia with nail dystrophy, results. Orf paronychia was treated with topical and untreated acute paronychia. Approval of the antibiotic cream. Herpetic paronychia was treated ethics committee was deferred because the study with systemic acyclovir tablets or syrup. Drugneither affected routine treatment of patients nor induced paronychia was treated by decreasing the required any intervention. drug dosage and prescribing topical steroid and antibiotic creams. Paronychia caused by pemphigus Tzanck smear: Preparation and evaluation vulgaris was treated with systemic corticosteroids. Each lesion was cleaned with a 70% alcohol swab. A small incision was made at the edge of the lesion and tissue was scraped through this incision RESULTS (slit-skin smear). All incisions were made superfiThe 58 patients included in the study were aged cially to avoid excessive bleeding. The cellular from 1 month to 91 years; most patients were tissue obtained was spread as a thin layer onto 2 children and adolescents, and there were more or more microscopic slides and air dried. All specfemale than male patients (Table I). There were imens were stained with May-Gr€ unwald-Giemsa more lesions in the hands than the feet (Table II). In (Bio-Optica, Milan, Italy). When numerous cocci 10 patients, there was multiple nail involvement; in and bacilli were detected in the smear, a Gram stain 1 of these patients who had herpetic paronychia, all was performed. In specimens showing only acan10 fingernails were involved. The mean duration of tholytic cells on cytologic examination, direct imparonychia was 13 days (7-21 days), and all patients munofluorescence microscopy was performed. The had used antibiotics previously with no response. stained preparations were evaluated under a light Cytologic examination, performed on all patients, microscope by a dermatologist (310 and 340 showed diagnostic findings in 54 patients (93%) magnification; 3100 magnification with immersion (Table I). The most common cause of antibioticoil). The clinical and cytologic findings were photoresistant paronychia was bacterial infection (cocci or graphed with a digital camera (resolution, 1600 3 bacilli), most commonly Staphylococcus aureus 1200 pixels) (Kodak EasyShare Z700, Kodak, (Table I and Fig 2 [available at http://www.jaad. Rochester, NY), and the images were stored in org]). Acantholytic cells were observed in 5 patients compressed (4:1) Joint Photographic Experts Group who had bacterial paronychia caused by format. Staphylococcus aureus. However, most patients diagnosis by dermatologic examination alone. We developed an algorithmic approach for the diagnosis and therapy of acute paronychia using the Tzanck smear findings. The purpose of this retrospective study was to describe the clinical, etiologic, cytologic, and therapeutic features of acute paronychias that did not respond to antibiotic treatment. d
d
d
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Fig 1. Diagnostic and therapeutic algorithm in patients with acute paronychia.
(33 patients [57%]) had nonbacterial causes of acute paronychia (Table I). Viral paronychia was the second most frequent cause of antibiotic-resistant paronychia, most commonly in children who had herpes infections such as herpes stomatitis and herpes labialis (Table I and Fig 3). Acantholytic and multinucleated giant cells were noted in all patients who had herpetic paronychia (Fig 3), and prominent eosinophilic (Cowdry type A) inclusion bodies were detected in 3 patients who had herpetic paronychia. Adult viral paronychia most commonly was caused by orf virus (Table I and Fig 4); in all 10 patients who had orf paronychia, cytology showed necrotic keratinocytes, inflammatory cells, and Guarnieri inclusion bodies in the keratinocytes, usually surrounded by a clear halo (Fig 4). Fungal paronychia was observed most commonly in children who had a habit of thumb-sucking (Table I and Fig 5). Cytology showed pseudohyphae
and spores in all patients who had candidal paronychia (Fig 5). Dermatophytic paronychia was observed in 1 adult patient who had intertriginous tinea pedis for 1 year, and Tzanck smear showed hyphae and spores (Fig 6). Acute paronychia caused by pemphigus vulgaris was detected in 3 patients (Table I and Fig 7 [available at http://www.jaad.org]). Oral and cutaneous erosive lesions were present in all 3 patients and conjunctival lesions in 2 patients who had pemphigus vulgaris. Acantholytic cells were present in all pemphigus lesions (Fig 7), and direct immunofluorescence on the cytologic smears showed IgG deposition around the cells in all pemphigus paronychias. Specific cytologic findings were absent in only 4 patients who had paronychia (3 drug-induced and 1 traumatic) (Fig 8 [available at http://www.jaad.org]). Abundant tadpole cells were detected the patient who had traumatic paronychia (Fig 8), and radiography showed soft-tissue swelling. Drug-induced multiple
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Table I. Demographic and clinical characteristics of patients who had antibiotic-resistant acute paronychia* Characteristics
No. of patients Sex Female Male Mean age (range) Cause of paronychiay Bacteriaz Gram-positive Gram-negative Virus Herpes Orf Fungus Candida Dermatophyte (tinea pedis) Drugs (isotretinoin) Pemphigus vulgaris Trauma Predisposing factors Finger- or thumb-suckingx Nail-bitingx Contact with animals Frequent hand washing Immunosuppressionk Playing with water Ripping the hangnail Trauma Prolonged use of antibiotics None or unknown
All patients
58 (100) 33 (57) 25 (43) 25 y (1 mo-91 y)
Adults (age [18 y)
22 (38) 17 (77) 5 (23) 32 y (19-91 y)
Children and adolescents (age \18 y)
36 (62) 16 (44) 20 (56) 8 y (1 mo-17 y)
25 20 5 21 11 10 5 4 1 3 3 1
(43) (34) (9) (36) (19) (17) (9) (7) (2) (5) (5) (2)
9 5 4 8 1 7 1 0 1 2 2 0
(41) (23) (18) (36) (5) (32) (5) (0) (5) (9) (9) (0)
16 15 1 13 10 3 4 4 0 1 1 1
(44) (42) (3) (36) (28) (8) (11) (11) (0) (3) (3) (3)
14 11 10 5 5 4 2 1 1 4
(24) (19) (17) (9) (9) (7) (3) (2) (2) (9)
0 3 7 5 0 0 2 0 1 4
(0) (14) (32) (23) (0) (0) (9) (0) (5) (18)
14 8 3 0 5 4 0 1 0 1
(39) (22) (8) (0) (14) (11) (0) (3) (0) (3)
*N = 58 patients. Data reported as number (%) or mean (range, minimum to maximum). y Diagnostic cytologic findings were noted in 54 patients (93%); no diagnostic cytologic findings were evident with drug-induced (3 patients) or traumatic (1 patient) paronychia. z The causative bacteria were Staphylococcus aureus (15 patients), Streptococcus pyogenes (5 patients), Pseudomonas aeruginosa (3 patients), and Proteus vulgaris (2 patients). x Finger- or thumb-sucking and nail-biting combined, 25 patients (43%): bacterial paronychia, 12 patients; herpetic paronychia, 10 patients; candidal paronychia, 3 patients. k Bacterial paronychia associated with immunosuppressive conditions (5 patients): 4 patients had chemotherapy for solid or hematologic malignancies and 1 patient had X-linked agammaglobulinemia.
paronychias were caused by systemic isotretinoin therapy in 3 patients who had acne vulgaris (Table I and Fig 9 [available at http://www.jaad.org]), and cytology showed no bacterial, fungal, or viral involvement; the lesions in these patients regressed after decreasing the dose of systemic isotretinoin. The most common predisposing factors for paronychia were the habits of finger- or thumb-sucking or nail-biting, which were associated with bacterial, herpetic, and candidal paronychia (Table I). All child patients who had herpetic paronychia had the habit of finger-sucking, except 1 patient who had the habit of nail-biting. Contact with animals was noted in 10 patients who had paronychia, including 3 patients who had orf virus paronychia after contact with sheep 2 to 4 weeks before admission. There were 5
patients who had bacterial paronychia associated with congenital or acquired immunosuppressive conditions, including 4 patients who were being treated with chemotherapy for solid or hematologic malignancies and 1 child (age, 3 years) in whom acute paronychia was the first manifestation of Xlinked agammaglobulinemia. Most patients had only 1 finger that had paronychia, most commonly the index finger or thumb (Table II). The ring or small finger was involved only in patients who had herpetic paronychia. There were 6 (10%) patients who had 2 digits involved, including the thumb and hallux. The 4 patients who had multiple fingers involved had drug-induced paronychia (3 patients) or herpetic paronychia (1 patient) (Table II).
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Table II. Anatomic distribution of antibiotic-resistant acute paronychia* Cause of paronychia Anatomic site
All
Thumb or hallux Index finger Long finger Ring finger Small finger Thumb and hallux Multiple fingersy Total
18 20 8 1 1 6 4 58
(31) (34) (14) (2) (2) (10) (7) (100)
Bacteria
Orf
Herpes
Candida
Drug
Pemphigus vulgaris
Trauma
11 8 4 0 0 2 0 25
0 7 3 0 0 0 0 10
2 4 0 1 1 2 1 11
4 1 0 0 0 0 0 5
0 0 0 0 0 0 3 3
1 0 0 0 0 2 0 3
0 0 1 0 0 0 0 1
*N = 58 patients. There were 48 patients (83%) who had only 1 finger or toe that had paronychia. Data reported as number (%) or number. y Multiple fingers involved: drug-induced paronychia, 3 patients; herpetic paronychia, 1 patient.
Fig 3. Acute herpetic paronychia. A and B, Acute herpetic paronychia, with the accumulation of purulent debris under the proximal nailfold, in a 12-year-old girl who had herpes labialis (arrow) and a habit of nail-biting. C, Acute herpetic paronychia on the index finger of an 18-month-old child who had herpes labialis and habit of thumb-sucking. D, Tzanck smear shows multinucleated giant cells (black arrow) and acantholytic cells (red arrows) in specimens from patients who had herpetic paronychia. (D, May-Gr€ unwald-Giemsa stain; original magnification: 31000.)
On initial treatment, all 58 patients received antibiotics, mostly oral penicillin or cephalosporin; 2 patients used macrolide antibiotics. Incision and drainage was performed in 40 (69%) patients, including all patients who had herpetic and orf virus paronychia. An id reaction developed in 3 patients (5%). Target lesions, erythematous papules, and plaques developed in 2 patients who had orf virus and 1 patient who had herpetic paronychia (Fig 10 [available at http://www.jaad.org]). These lesions
were observed on the hands and forearms 1 to 2 weeks after initial evaluation. Histopathologic examination of these target lesions showed erythema multiforme. The lesions were treated with topical corticosteroid cream and resolved within 2 weeks.
DISCUSSION In this study, cytologic examination showed varied infectious and noninfectious causes of acute paronychia. There is limited previous information about
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Fig 4. Orf virus paronychia. A, Orf virus paronychia on the index finger of an 11-year-old boy who had a history of contact with animals. B, Tzanck smear shows intracytoplasmic Guarnieri bodies (arrows). (B, May-Gr€ unwaldGiemsa stain; original magnification: 31000.)
Fig 5. Candidal paronychia. A, Candidal paronychia of a thumb, with erythema, edema, and crusting on the lateral and proximal nailfold. B, Cytology shows pseudohyphae (black arrow) and spores (red arrows). (B, MayGr€ unwald-Giemsa stain; original magnification: 31000.)
the clinical and cytologic features of patients who have systemic antibiotic-resistant acute paronychia. Antibiotic-resistant acute paronychia may be caused by methicillin-resistant Staphylococcus aureus.10 Other bacterial causes of paronychia in the current study included Streptococcus pyogenes, Pseudomonas aeruginosa, and Proteus vulgaris (Table I), and previous studies have reported paronychia caused by Prevotella bivia, Treponema pallidum, and Bartonella henselae.11-16 Viral infection was a frequent cause of antibioticresistant paronychia, especially infection from orf virus in adults and herpesvirus in children (Table I). Orf virus may be transmitted to human beings by direct or indirect contact with infected sheep or
Durdu and Ruocco 125
Fig 6. Dermatophytic paronychia. A, Vesiculobullous tinea pedis on the proximal nailfold of a hallux. B, Tzanck smear shows hyphae (arrow) and spores. (B, MayGr€ unwald-Giemsa stain; original magnification: 31000.)
goats.17 Patients reported contact with animals at the Feast of the Sacrifice. (Feast of the Sacrifice is an important religious holiday celebrated by Muslims worldwide. Muslims cut sacrificial animals on this holiday.) Orf virus may cause lesions on the fingers, hands, or forearms, but the current patients had lesions from orf virus only on the index and long fingers. Children may be infected by orf virus less frequently than adults (Table I).18 Herpetic paronychia occurred in children after selfinoculation from herpes stomatitis or herpes labialis, as previously described.3 Similar to previous studies, most patients in the current study who had herpetic paronychia were younger than 2 years. Multiple finger involvement has rarely been reported with herpetic paronychia,3 and only 1 patient in the current study who had herpetic paronychia had involvement of all 10 fingers because of a habit of nail-biting (Fig 3). Yeast fungi may cause chronic or acute paronychia.19,20 In the current study, candidal paronychia is observed in 4 children who had oral candidiasis and a habit of thumb-sucking (Table I). Only 1 patient had dermatophytic paronychia caused by vesiculobullous tinea pedis (Table I and Fig 6). Trauma and terminal phalanx fractures can mimic acute paronychia. In a previous study, 4 patients who had terminal phalanx fractures were initially misdiagnosed as having acute paronychia; therefore, radiography is advised to evaluate for a possible fracture when acute paronychia occurs after trauma.21 In the patient who had traumatic paronychia, radiography showed no fracture, but abundant tadpole cells were observed (Table I and Fig 8). Tadpole cells may be observed in many skin diseases, but the presence of more than 10 tadpole cells at 100-fold magnification is specific for spongiotic dermatitis.7
126 Durdu and Ruocco
This study confirmed that acute paronychia may develop in patients who have noninfectious disorders, including 3 patients who had acute paronychia associated with pemphigus vulgaris (Table I and Fig 7). Periungual involvement may be observed with pemphigus vulgaris and may mimic acute or chronic paronychia. Paronychia (acute or chronic) may present in 52% with pemphigus. Paronychia may be observed during the initial presentation, disease relapse, or before an exacerbation of pemphigus vulgaris.22-24 Complications of acute paronychia may include osteitis and amputation.12 Acquired periungual fibrokeratoma after staphylococcal paronychia has been reported.25 In addition, herpetic paronychia may cause complete destruction of the nail, bacterial superinfection, and systemic spread that may cause meningitis.26-28 In the current study, erythema multiforme was observed in patients who had paronychias caused by orf and herpes viruses, as previously described.29,30 The most common predisposing factors for acute paronychia were the habits of thumb-sucking and nail-biting, as previously described (Table I).31 Nailbiting may be observed in 28% to 33% of children aged 7 to 10 years.32 In addition, cutaneous infections may be the first sign of immunosuppressive diseases such as X-linked agammaglobulinemia, observed in 1 patient (Table I). Limitations of this study include the retrospective study design and inclusion of patients from only 1 treatment center. In summary, antibiotic-resistant acute paronychia may be infectious or noninfectious, caused by diverse micro-organisms, and associated with diverse predisposing factors. This study shows that cytologic examination may be useful diagnostically and may prevent unnecessary use of antibiotics and surgical drainage procedures. REFERENCES 1. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician 2008;77:339-46. 2. Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001;63:1113-6. 3. Szinnai G, Schaad UB, Heininger U. Multiple herpetic whitlow lesions in a 4-year-old girl: case report and review of the literature. Eur J Pediatr 2001;160:528-33. 4. Cohen PR. Community-acquired methicillin-resistant Staphylococcus aureus skin infections: implications for patients and practitioners. Am J Clin Dermatol 2007;8:259-70. 5. Feder HM Jr, Long SS. Herpetic whitlow: epidemiology, clinical characteristics, diagnosis, and treatment. Am J Dis Child 1983; 137:861-3. 6. Ruocco E, Brunetti G, Del Vecchio M, Ruocco V. The practical use of cytology for diagnosis in dermatology. J Eur Acad Dermatol Venereol 2011;25:125-9.
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7. Durdu M, Baba M, Sec¸kin D. The value of Tzanck smear test in diagnosis of erosive, vesicular, bullous, and pustular skin lesions. J Am Acad Dermatol 2008;59:958-64. 8. Durdu M, Sec¸kin D, Baba M. The Tzanck smear test: rediscovery of a practical diagnostic tool. Skinmed 2011;9:23-32. 9. Ruocco V, Ruocco E. Tzanck smear, an old test for the new millennium: when and how. Int J Dermatol 1999;38:830-4. 10. McGinley KJ, Larson EL, Leyden JJ. Composition and density of microflora in the subungual space of the hand. J Clin Microbiol 1988;26:950-3. 11. Barton LL, Anderson LE. Paronychia caused by HB-1 organisms. Pediatrics 1974;54:372-3. 12. Riesbeck K. Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological diagnosis is crucial. J Clin Microbiol 2003;41:4901-3. 13. Starzycki Z. Primary syphilis of the fingers. Br J Vener Dis 1983; 59:169-71. 14. Kingsbury DH, Chester EC Jr, Jansen GT. Syphilitic paronychia: an unusual complaint. Arch Dermatol 1972;105:458. 15. De Koning GA, Blog FB, Stolz E. A patient with primary syphilis of the hand. Br J Vener Dis 1977;53:386-8. 16. Sander A, Frank B. Paronychia caused by Bartonella henselae. Lancet 1997;350:1078. 17. Perna AG, Tyring SK. A review of the dermatologic manifestations of poxvirus infections. Dermatol Clin 2002;20:343-6. 18. Lederman ER, Austin C, Trevino I, Reynolds MG, Swanson H, Cherry B, et al. ORF virus infection in children: clinical characteristics, transmission, diagnostic methods, and future therapeutics. Pediatr Infect Dis J 2007;26:740-4. 19. Bonifaz A, Paredes V, Fierro L, L opez-Lozano H, de la Herran P, Vazquez-Gonzalez D. Paronychia. Skinmed 2013;11:14-6. 20. Montemarano AD, Benson PM, James WD, Crowe MA. Acute paronychia apparently caused by Candida albicans in a healthy female. Arch Dermatol 1993;129:786-7. 21. Guly HR. Fractures of the terminal phalanx presenting as a paronychia. Arch Emerg Med 1993;10:301-5. 22. Lee HE, Wong WR, Lee MC, Hong HS. Acute paronychia heralding the exacerbation of pemphigus vulgaris. Int J Clin Pract 2004;58:1174-6. 23. Habibi M, Mortazavi H, Shadianloo S, Balighi K, Ghodsi SZ, Daneshpazhooh M, et al. Nail changes in pemphigus vulgaris. Int J Dermatol 2008;47:1141-4. 24. Engineer L, Norton LA, Ahmed AR. Nail involvement in pemphigus vulgaris. J Am Acad Dermatol 2000;43:529-35. 25. Sezer E, Bridges AG, Koseoglu D, Yuksek J. Acquired periungual fibrokeratoma developing after acute staphylococcal paronychia. Eur J Dermatol 2009;19:636-7. 26. Hurst LC, Gluck R, Sampson SP, Dowd A. Herpetic whitlow with bacterial abscess. J Hand Surg Am 1991;16:311-4. 27. Karpathios T, Moustaki M, Yiallouros P, Sarifi F, Tzanakaki G, Fretzayas A. HSV-2 meningitis disseminated from a herpetic whitlow. Paediatr Int Child Health 2012;32:121-2. 28. Robayna MG, Herranz P, Rubio FA, Pe~ na P, Pe~ na JM, Gonzalez J, et al. Destructive herpetic whitlow in AIDS: report of three cases. Br J Dermatol 1997;137:812-5. 29. Ilkit M, Durdu M, Karakas¸ M. Cutaneous id reactions: a comprehensive review of clinical manifestations, epidemiology, etiology, and management. Crit Rev Microbiol 2012;38:191-202. 30. de Ocariz MM, Vega-Memije ME, Mu~ noz-Hink H. A case of herpetic whitlow associated with erythema multiforme. Pediatr Dermatol 1998;15:384-5. 31. Whitehead SM, Eykyn SJ, Phillips I. Anaerobic paronychia. Br J Surg 1981;68:420-2. 32. Leung AK, Robson WL. Nailbiting. Clin Pediatr (Phila) 1990;29: 690-2.
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Fig 2. Acute bacterial paronychia. A, Accumulation of purulent debris is noted at the junction between the proximal and lateral nailfolds. B, Tzanck smear shows abundant cocci (arrows). (B, May-Gr€ unwald-Giemsa stain; original magnification: 31000.)
Fig 7. Pemphigus vulgaris paronychia. A, Paronychia caused by pemphigus vulgaris on a thumb. B, Cytology shows acantholytic cells (arrows). (B, May-Gr€ unwaldGiemsa stain; original magnification: 31000.)
Durdu and Ruocco 126.e1
Fig 8. Acute traumatic paronychia. A, A 9-year-old boy had a crush injury of his thumb in a door jamb and developed an acute paronychia, with accumulation of purulent debris under the proximal nailfold. B, Tzanck smear shows tadpole cells (arrows) without bacteria, hyphae, or spores. (B, May-Gr€ unwald-Giemsa stain; original magnification: 31000.)
Fig 9. Drug-induced paronychia. Erythema and edema on the lateral and proximal nailfold of the ring finger in a 13-year-old girl after systemic isotretinoin therapy.
Fig 10. Postherpetic erythema multiforme. Hemorrhagic vesicles and brown-black crust on the small and long fingers, partially confluent erythematous papules and plaques, and target formation on the hand.
cute paronychia usually is caused by infection, and bacteria are the most common causative organisms. In addition, herpes virus, orf virus, and some fungi can cause acute paronychia.1,2 However, acute paronychia usually is treated as a bacterial infection. Most (65%) herpetic paronychias are initially misdiagnosed as bacterial paronychia.3 Therefore, topical and systemic antibiotics frequently are prescribed and may be misused for several weeks. The unnecessary use of antibiotics may cause the development of antibiotic-resistant bacteria.4 Surgical drainage without antibiotic
A
therapy may be an acceptable treatment in most patients who have acute paronychia, but it is important to distinguish nonbacterial from bacterial paronychia; viral paronychia may be a self-limiting infection for which surgical treatment is not indicated.5 Cytology is a simple, rapid, reliable, and inexpensive diagnostic method that has been used for the diagnosis of various infectious and noninfectious cutaneous diseases.6-9 In our clinic, we have been performing the Tzanck smear regularly during the past 7 years for patients who could not be given a
From the Bas¸kent University Faculty of Medicine, Department of Dermatology, Adana Hospitala; and Department of Dermatology, Second University of Naples.b Funding sources: None. Conflicts of interest: None declared. Accepted for publication September 25, 2013. Reprints not available from the authors.
Correspondence to: Murat Durdu, MD, Bas¸kent University Faculty of Medicine, Department of Dermatology, Adana Hospital, Seyhan, 01130, Adana, Turkey. E-mail: [email protected]. 0190-9622/$36.00 Ó 2013 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2013.09.042
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Definitive diagnosis Diagnoses of herpetic paronychia, orf virus paronychia, fungal paronychia, and paronychia caused by pemphigus vulgaris were made by evaluating the cytologic features and laboratory findings, including bacterial and fungal cultures and direct immunofluorescence tests on the cytologic smears (Fig 1). When paronychia developed after the use of drugs and CAPSULE SUMMARY there were no diagnostic cytologic findings, the paroMETHODS Acute paronychia usually is treated as a nychia was diagnosed as Patients bacterial infection. drug induced. When paroThis study was conducted In 58 patients who had antibioticnychia developed after between February 2011 resistant acute paronychia, 33 patients trauma and there were no and February 2013 at the (57%) had nonbacterial causes; cytology diagnostic cytologic findings, Department of Dermatology, (Tzanck smear) showed diagnostic the paronychia was diagBas¸kent University Faculty of findings in 54 patients (93%). nosed as traumatic. Medicine, Adana Teaching In paronychia, cytology may improve and Medical Research diagnosis and prevent unnecessary Center, Adana, Turkey. We Treatment antibiotics and surgical drainage. retrospectively analyzed the Bacterial paronychia was medical records of all patients treated with antibiotics acwho had acute paronychia cording to the results of antibiotic susceptibility that was resistant to systemic antibiotic. The clinical testing. Fungal paronychia was treated initially with and cytologic findings were recorded. Patients were itraconazole (100 mg twice daily for 2 weeks) and excluded because of paronychia caused by an insubsequently according to antifungal susceptibility grown nail, chronic paronychia with nail dystrophy, results. Orf paronychia was treated with topical and untreated acute paronychia. Approval of the antibiotic cream. Herpetic paronychia was treated ethics committee was deferred because the study with systemic acyclovir tablets or syrup. Drugneither affected routine treatment of patients nor induced paronychia was treated by decreasing the required any intervention. drug dosage and prescribing topical steroid and antibiotic creams. Paronychia caused by pemphigus Tzanck smear: Preparation and evaluation vulgaris was treated with systemic corticosteroids. Each lesion was cleaned with a 70% alcohol swab. A small incision was made at the edge of the lesion and tissue was scraped through this incision RESULTS (slit-skin smear). All incisions were made superfiThe 58 patients included in the study were aged cially to avoid excessive bleeding. The cellular from 1 month to 91 years; most patients were tissue obtained was spread as a thin layer onto 2 children and adolescents, and there were more or more microscopic slides and air dried. All specfemale than male patients (Table I). There were imens were stained with May-Gr€ unwald-Giemsa more lesions in the hands than the feet (Table II). In (Bio-Optica, Milan, Italy). When numerous cocci 10 patients, there was multiple nail involvement; in and bacilli were detected in the smear, a Gram stain 1 of these patients who had herpetic paronychia, all was performed. In specimens showing only acan10 fingernails were involved. The mean duration of tholytic cells on cytologic examination, direct imparonychia was 13 days (7-21 days), and all patients munofluorescence microscopy was performed. The had used antibiotics previously with no response. stained preparations were evaluated under a light Cytologic examination, performed on all patients, microscope by a dermatologist (310 and 340 showed diagnostic findings in 54 patients (93%) magnification; 3100 magnification with immersion (Table I). The most common cause of antibioticoil). The clinical and cytologic findings were photoresistant paronychia was bacterial infection (cocci or graphed with a digital camera (resolution, 1600 3 bacilli), most commonly Staphylococcus aureus 1200 pixels) (Kodak EasyShare Z700, Kodak, (Table I and Fig 2 [available at http://www.jaad. Rochester, NY), and the images were stored in org]). Acantholytic cells were observed in 5 patients compressed (4:1) Joint Photographic Experts Group who had bacterial paronychia caused by format. Staphylococcus aureus. However, most patients diagnosis by dermatologic examination alone. We developed an algorithmic approach for the diagnosis and therapy of acute paronychia using the Tzanck smear findings. The purpose of this retrospective study was to describe the clinical, etiologic, cytologic, and therapeutic features of acute paronychias that did not respond to antibiotic treatment. d
d
d
122 Durdu and Ruocco
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Fig 1. Diagnostic and therapeutic algorithm in patients with acute paronychia.
(33 patients [57%]) had nonbacterial causes of acute paronychia (Table I). Viral paronychia was the second most frequent cause of antibiotic-resistant paronychia, most commonly in children who had herpes infections such as herpes stomatitis and herpes labialis (Table I and Fig 3). Acantholytic and multinucleated giant cells were noted in all patients who had herpetic paronychia (Fig 3), and prominent eosinophilic (Cowdry type A) inclusion bodies were detected in 3 patients who had herpetic paronychia. Adult viral paronychia most commonly was caused by orf virus (Table I and Fig 4); in all 10 patients who had orf paronychia, cytology showed necrotic keratinocytes, inflammatory cells, and Guarnieri inclusion bodies in the keratinocytes, usually surrounded by a clear halo (Fig 4). Fungal paronychia was observed most commonly in children who had a habit of thumb-sucking (Table I and Fig 5). Cytology showed pseudohyphae
and spores in all patients who had candidal paronychia (Fig 5). Dermatophytic paronychia was observed in 1 adult patient who had intertriginous tinea pedis for 1 year, and Tzanck smear showed hyphae and spores (Fig 6). Acute paronychia caused by pemphigus vulgaris was detected in 3 patients (Table I and Fig 7 [available at http://www.jaad.org]). Oral and cutaneous erosive lesions were present in all 3 patients and conjunctival lesions in 2 patients who had pemphigus vulgaris. Acantholytic cells were present in all pemphigus lesions (Fig 7), and direct immunofluorescence on the cytologic smears showed IgG deposition around the cells in all pemphigus paronychias. Specific cytologic findings were absent in only 4 patients who had paronychia (3 drug-induced and 1 traumatic) (Fig 8 [available at http://www.jaad.org]). Abundant tadpole cells were detected the patient who had traumatic paronychia (Fig 8), and radiography showed soft-tissue swelling. Drug-induced multiple
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Table I. Demographic and clinical characteristics of patients who had antibiotic-resistant acute paronychia* Characteristics
No. of patients Sex Female Male Mean age (range) Cause of paronychiay Bacteriaz Gram-positive Gram-negative Virus Herpes Orf Fungus Candida Dermatophyte (tinea pedis) Drugs (isotretinoin) Pemphigus vulgaris Trauma Predisposing factors Finger- or thumb-suckingx Nail-bitingx Contact with animals Frequent hand washing Immunosuppressionk Playing with water Ripping the hangnail Trauma Prolonged use of antibiotics None or unknown
All patients
58 (100) 33 (57) 25 (43) 25 y (1 mo-91 y)
Adults (age [18 y)
22 (38) 17 (77) 5 (23) 32 y (19-91 y)
Children and adolescents (age \18 y)
36 (62) 16 (44) 20 (56) 8 y (1 mo-17 y)
25 20 5 21 11 10 5 4 1 3 3 1
(43) (34) (9) (36) (19) (17) (9) (7) (2) (5) (5) (2)
9 5 4 8 1 7 1 0 1 2 2 0
(41) (23) (18) (36) (5) (32) (5) (0) (5) (9) (9) (0)
16 15 1 13 10 3 4 4 0 1 1 1
(44) (42) (3) (36) (28) (8) (11) (11) (0) (3) (3) (3)
14 11 10 5 5 4 2 1 1 4
(24) (19) (17) (9) (9) (7) (3) (2) (2) (9)
0 3 7 5 0 0 2 0 1 4
(0) (14) (32) (23) (0) (0) (9) (0) (5) (18)
14 8 3 0 5 4 0 1 0 1
(39) (22) (8) (0) (14) (11) (0) (3) (0) (3)
*N = 58 patients. Data reported as number (%) or mean (range, minimum to maximum). y Diagnostic cytologic findings were noted in 54 patients (93%); no diagnostic cytologic findings were evident with drug-induced (3 patients) or traumatic (1 patient) paronychia. z The causative bacteria were Staphylococcus aureus (15 patients), Streptococcus pyogenes (5 patients), Pseudomonas aeruginosa (3 patients), and Proteus vulgaris (2 patients). x Finger- or thumb-sucking and nail-biting combined, 25 patients (43%): bacterial paronychia, 12 patients; herpetic paronychia, 10 patients; candidal paronychia, 3 patients. k Bacterial paronychia associated with immunosuppressive conditions (5 patients): 4 patients had chemotherapy for solid or hematologic malignancies and 1 patient had X-linked agammaglobulinemia.
paronychias were caused by systemic isotretinoin therapy in 3 patients who had acne vulgaris (Table I and Fig 9 [available at http://www.jaad.org]), and cytology showed no bacterial, fungal, or viral involvement; the lesions in these patients regressed after decreasing the dose of systemic isotretinoin. The most common predisposing factors for paronychia were the habits of finger- or thumb-sucking or nail-biting, which were associated with bacterial, herpetic, and candidal paronychia (Table I). All child patients who had herpetic paronychia had the habit of finger-sucking, except 1 patient who had the habit of nail-biting. Contact with animals was noted in 10 patients who had paronychia, including 3 patients who had orf virus paronychia after contact with sheep 2 to 4 weeks before admission. There were 5
patients who had bacterial paronychia associated with congenital or acquired immunosuppressive conditions, including 4 patients who were being treated with chemotherapy for solid or hematologic malignancies and 1 child (age, 3 years) in whom acute paronychia was the first manifestation of Xlinked agammaglobulinemia. Most patients had only 1 finger that had paronychia, most commonly the index finger or thumb (Table II). The ring or small finger was involved only in patients who had herpetic paronychia. There were 6 (10%) patients who had 2 digits involved, including the thumb and hallux. The 4 patients who had multiple fingers involved had drug-induced paronychia (3 patients) or herpetic paronychia (1 patient) (Table II).
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Table II. Anatomic distribution of antibiotic-resistant acute paronychia* Cause of paronychia Anatomic site
All
Thumb or hallux Index finger Long finger Ring finger Small finger Thumb and hallux Multiple fingersy Total
18 20 8 1 1 6 4 58
(31) (34) (14) (2) (2) (10) (7) (100)
Bacteria
Orf
Herpes
Candida
Drug
Pemphigus vulgaris
Trauma
11 8 4 0 0 2 0 25
0 7 3 0 0 0 0 10
2 4 0 1 1 2 1 11
4 1 0 0 0 0 0 5
0 0 0 0 0 0 3 3
1 0 0 0 0 2 0 3
0 0 1 0 0 0 0 1
*N = 58 patients. There were 48 patients (83%) who had only 1 finger or toe that had paronychia. Data reported as number (%) or number. y Multiple fingers involved: drug-induced paronychia, 3 patients; herpetic paronychia, 1 patient.
Fig 3. Acute herpetic paronychia. A and B, Acute herpetic paronychia, with the accumulation of purulent debris under the proximal nailfold, in a 12-year-old girl who had herpes labialis (arrow) and a habit of nail-biting. C, Acute herpetic paronychia on the index finger of an 18-month-old child who had herpes labialis and habit of thumb-sucking. D, Tzanck smear shows multinucleated giant cells (black arrow) and acantholytic cells (red arrows) in specimens from patients who had herpetic paronychia. (D, May-Gr€ unwald-Giemsa stain; original magnification: 31000.)
On initial treatment, all 58 patients received antibiotics, mostly oral penicillin or cephalosporin; 2 patients used macrolide antibiotics. Incision and drainage was performed in 40 (69%) patients, including all patients who had herpetic and orf virus paronychia. An id reaction developed in 3 patients (5%). Target lesions, erythematous papules, and plaques developed in 2 patients who had orf virus and 1 patient who had herpetic paronychia (Fig 10 [available at http://www.jaad.org]). These lesions
were observed on the hands and forearms 1 to 2 weeks after initial evaluation. Histopathologic examination of these target lesions showed erythema multiforme. The lesions were treated with topical corticosteroid cream and resolved within 2 weeks.
DISCUSSION In this study, cytologic examination showed varied infectious and noninfectious causes of acute paronychia. There is limited previous information about
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Fig 4. Orf virus paronychia. A, Orf virus paronychia on the index finger of an 11-year-old boy who had a history of contact with animals. B, Tzanck smear shows intracytoplasmic Guarnieri bodies (arrows). (B, May-Gr€ unwaldGiemsa stain; original magnification: 31000.)
Fig 5. Candidal paronychia. A, Candidal paronychia of a thumb, with erythema, edema, and crusting on the lateral and proximal nailfold. B, Cytology shows pseudohyphae (black arrow) and spores (red arrows). (B, MayGr€ unwald-Giemsa stain; original magnification: 31000.)
the clinical and cytologic features of patients who have systemic antibiotic-resistant acute paronychia. Antibiotic-resistant acute paronychia may be caused by methicillin-resistant Staphylococcus aureus.10 Other bacterial causes of paronychia in the current study included Streptococcus pyogenes, Pseudomonas aeruginosa, and Proteus vulgaris (Table I), and previous studies have reported paronychia caused by Prevotella bivia, Treponema pallidum, and Bartonella henselae.11-16 Viral infection was a frequent cause of antibioticresistant paronychia, especially infection from orf virus in adults and herpesvirus in children (Table I). Orf virus may be transmitted to human beings by direct or indirect contact with infected sheep or
Durdu and Ruocco 125
Fig 6. Dermatophytic paronychia. A, Vesiculobullous tinea pedis on the proximal nailfold of a hallux. B, Tzanck smear shows hyphae (arrow) and spores. (B, MayGr€ unwald-Giemsa stain; original magnification: 31000.)
goats.17 Patients reported contact with animals at the Feast of the Sacrifice. (Feast of the Sacrifice is an important religious holiday celebrated by Muslims worldwide. Muslims cut sacrificial animals on this holiday.) Orf virus may cause lesions on the fingers, hands, or forearms, but the current patients had lesions from orf virus only on the index and long fingers. Children may be infected by orf virus less frequently than adults (Table I).18 Herpetic paronychia occurred in children after selfinoculation from herpes stomatitis or herpes labialis, as previously described.3 Similar to previous studies, most patients in the current study who had herpetic paronychia were younger than 2 years. Multiple finger involvement has rarely been reported with herpetic paronychia,3 and only 1 patient in the current study who had herpetic paronychia had involvement of all 10 fingers because of a habit of nail-biting (Fig 3). Yeast fungi may cause chronic or acute paronychia.19,20 In the current study, candidal paronychia is observed in 4 children who had oral candidiasis and a habit of thumb-sucking (Table I). Only 1 patient had dermatophytic paronychia caused by vesiculobullous tinea pedis (Table I and Fig 6). Trauma and terminal phalanx fractures can mimic acute paronychia. In a previous study, 4 patients who had terminal phalanx fractures were initially misdiagnosed as having acute paronychia; therefore, radiography is advised to evaluate for a possible fracture when acute paronychia occurs after trauma.21 In the patient who had traumatic paronychia, radiography showed no fracture, but abundant tadpole cells were observed (Table I and Fig 8). Tadpole cells may be observed in many skin diseases, but the presence of more than 10 tadpole cells at 100-fold magnification is specific for spongiotic dermatitis.7
126 Durdu and Ruocco
This study confirmed that acute paronychia may develop in patients who have noninfectious disorders, including 3 patients who had acute paronychia associated with pemphigus vulgaris (Table I and Fig 7). Periungual involvement may be observed with pemphigus vulgaris and may mimic acute or chronic paronychia. Paronychia (acute or chronic) may present in 52% with pemphigus. Paronychia may be observed during the initial presentation, disease relapse, or before an exacerbation of pemphigus vulgaris.22-24 Complications of acute paronychia may include osteitis and amputation.12 Acquired periungual fibrokeratoma after staphylococcal paronychia has been reported.25 In addition, herpetic paronychia may cause complete destruction of the nail, bacterial superinfection, and systemic spread that may cause meningitis.26-28 In the current study, erythema multiforme was observed in patients who had paronychias caused by orf and herpes viruses, as previously described.29,30 The most common predisposing factors for acute paronychia were the habits of thumb-sucking and nail-biting, as previously described (Table I).31 Nailbiting may be observed in 28% to 33% of children aged 7 to 10 years.32 In addition, cutaneous infections may be the first sign of immunosuppressive diseases such as X-linked agammaglobulinemia, observed in 1 patient (Table I). Limitations of this study include the retrospective study design and inclusion of patients from only 1 treatment center. In summary, antibiotic-resistant acute paronychia may be infectious or noninfectious, caused by diverse micro-organisms, and associated with diverse predisposing factors. This study shows that cytologic examination may be useful diagnostically and may prevent unnecessary use of antibiotics and surgical drainage procedures. REFERENCES 1. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician 2008;77:339-46. 2. Rockwell PG. Acute and chronic paronychia. Am Fam Physician 2001;63:1113-6. 3. Szinnai G, Schaad UB, Heininger U. Multiple herpetic whitlow lesions in a 4-year-old girl: case report and review of the literature. Eur J Pediatr 2001;160:528-33. 4. Cohen PR. Community-acquired methicillin-resistant Staphylococcus aureus skin infections: implications for patients and practitioners. Am J Clin Dermatol 2007;8:259-70. 5. Feder HM Jr, Long SS. Herpetic whitlow: epidemiology, clinical characteristics, diagnosis, and treatment. Am J Dis Child 1983; 137:861-3. 6. Ruocco E, Brunetti G, Del Vecchio M, Ruocco V. The practical use of cytology for diagnosis in dermatology. J Eur Acad Dermatol Venereol 2011;25:125-9.
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7. Durdu M, Baba M, Sec¸kin D. The value of Tzanck smear test in diagnosis of erosive, vesicular, bullous, and pustular skin lesions. J Am Acad Dermatol 2008;59:958-64. 8. Durdu M, Sec¸kin D, Baba M. The Tzanck smear test: rediscovery of a practical diagnostic tool. Skinmed 2011;9:23-32. 9. Ruocco V, Ruocco E. Tzanck smear, an old test for the new millennium: when and how. Int J Dermatol 1999;38:830-4. 10. McGinley KJ, Larson EL, Leyden JJ. Composition and density of microflora in the subungual space of the hand. J Clin Microbiol 1988;26:950-3. 11. Barton LL, Anderson LE. Paronychia caused by HB-1 organisms. Pediatrics 1974;54:372-3. 12. Riesbeck K. Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological diagnosis is crucial. J Clin Microbiol 2003;41:4901-3. 13. Starzycki Z. Primary syphilis of the fingers. Br J Vener Dis 1983; 59:169-71. 14. Kingsbury DH, Chester EC Jr, Jansen GT. Syphilitic paronychia: an unusual complaint. Arch Dermatol 1972;105:458. 15. De Koning GA, Blog FB, Stolz E. A patient with primary syphilis of the hand. Br J Vener Dis 1977;53:386-8. 16. Sander A, Frank B. Paronychia caused by Bartonella henselae. Lancet 1997;350:1078. 17. Perna AG, Tyring SK. A review of the dermatologic manifestations of poxvirus infections. Dermatol Clin 2002;20:343-6. 18. Lederman ER, Austin C, Trevino I, Reynolds MG, Swanson H, Cherry B, et al. ORF virus infection in children: clinical characteristics, transmission, diagnostic methods, and future therapeutics. Pediatr Infect Dis J 2007;26:740-4. 19. Bonifaz A, Paredes V, Fierro L, L opez-Lozano H, de la Herran P, Vazquez-Gonzalez D. Paronychia. Skinmed 2013;11:14-6. 20. Montemarano AD, Benson PM, James WD, Crowe MA. Acute paronychia apparently caused by Candida albicans in a healthy female. Arch Dermatol 1993;129:786-7. 21. Guly HR. Fractures of the terminal phalanx presenting as a paronychia. Arch Emerg Med 1993;10:301-5. 22. Lee HE, Wong WR, Lee MC, Hong HS. Acute paronychia heralding the exacerbation of pemphigus vulgaris. Int J Clin Pract 2004;58:1174-6. 23. Habibi M, Mortazavi H, Shadianloo S, Balighi K, Ghodsi SZ, Daneshpazhooh M, et al. Nail changes in pemphigus vulgaris. Int J Dermatol 2008;47:1141-4. 24. Engineer L, Norton LA, Ahmed AR. Nail involvement in pemphigus vulgaris. J Am Acad Dermatol 2000;43:529-35. 25. Sezer E, Bridges AG, Koseoglu D, Yuksek J. Acquired periungual fibrokeratoma developing after acute staphylococcal paronychia. Eur J Dermatol 2009;19:636-7. 26. Hurst LC, Gluck R, Sampson SP, Dowd A. Herpetic whitlow with bacterial abscess. J Hand Surg Am 1991;16:311-4. 27. Karpathios T, Moustaki M, Yiallouros P, Sarifi F, Tzanakaki G, Fretzayas A. HSV-2 meningitis disseminated from a herpetic whitlow. Paediatr Int Child Health 2012;32:121-2. 28. Robayna MG, Herranz P, Rubio FA, Pe~ na P, Pe~ na JM, Gonzalez J, et al. Destructive herpetic whitlow in AIDS: report of three cases. Br J Dermatol 1997;137:812-5. 29. Ilkit M, Durdu M, Karakas¸ M. Cutaneous id reactions: a comprehensive review of clinical manifestations, epidemiology, etiology, and management. Crit Rev Microbiol 2012;38:191-202. 30. de Ocariz MM, Vega-Memije ME, Mu~ noz-Hink H. A case of herpetic whitlow associated with erythema multiforme. Pediatr Dermatol 1998;15:384-5. 31. Whitehead SM, Eykyn SJ, Phillips I. Anaerobic paronychia. Br J Surg 1981;68:420-2. 32. Leung AK, Robson WL. Nailbiting. Clin Pediatr (Phila) 1990;29: 690-2.
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Fig 2. Acute bacterial paronychia. A, Accumulation of purulent debris is noted at the junction between the proximal and lateral nailfolds. B, Tzanck smear shows abundant cocci (arrows). (B, May-Gr€ unwald-Giemsa stain; original magnification: 31000.)
Fig 7. Pemphigus vulgaris paronychia. A, Paronychia caused by pemphigus vulgaris on a thumb. B, Cytology shows acantholytic cells (arrows). (B, May-Gr€ unwaldGiemsa stain; original magnification: 31000.)
Durdu and Ruocco 126.e1
Fig 8. Acute traumatic paronychia. A, A 9-year-old boy had a crush injury of his thumb in a door jamb and developed an acute paronychia, with accumulation of purulent debris under the proximal nailfold. B, Tzanck smear shows tadpole cells (arrows) without bacteria, hyphae, or spores. (B, May-Gr€ unwald-Giemsa stain; original magnification: 31000.)
Fig 9. Drug-induced paronychia. Erythema and edema on the lateral and proximal nailfold of the ring finger in a 13-year-old girl after systemic isotretinoin therapy.
Fig 10. Postherpetic erythema multiforme. Hemorrhagic vesicles and brown-black crust on the small and long fingers, partially confluent erythematous papules and plaques, and target formation on the hand.