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STUDIES
Year : 1992  |  Volume : 58  |  Issue : 2  |  Page : 73-76

Clinicomicrobiological study of chronic paronychia




Correspondence Address:
P K Guha


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  Abstract 

A total of 261 digits affected in 100 patients of chronic paronychia were studied for clinical features. The bacteriological and mycological flora have been examined in 25 cases of the above 100 cases which were most severely affected. Aerobic bacteria were found in all cases. Staphylococcus aureus was seen in 60 percent. Klebsiella in 16 percent, Escherichia coli in 12 percent, Pseudomonas aeruginosa in 12 percent, Proteus mirabillis in 8 percent, Staphylococcus epidermidis in 4 percent and Streptococcus viridans in 4 percent. Culture for fungus revealed Candida albicans in 64 percent and other species such as C. krusei, C. stellatoides, C. viswanathi, C. parapsilosis and C. tropicalis were present in 1 case each. No fungus was detected in 4 cases(16percent). The present investigation was designed to compare the bacterial and mycotic flora of the nail folds of patients of chronic paronychia with that of western countries.


Keywords: Chronic paronychia, Clinical, Microbiological, Study


How to cite this article:
Guha P K, Panja S K. Clinicomicrobiological study of chronic paronychia. Indian J Dermatol Venereol Leprol 1992;58:73-6

How to cite this URL:
Guha P K, Panja S K. Clinicomicrobiological study of chronic paronychia. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2020 Apr 6];58:73-6. Available from: http://www.ijdvl.com/text.asp?1992/58/2/73/3754



  Introduction Top


Chronic paronychia is one of the commonest nail complaints met with in dermatological practice. It is regarded as a troublesome and intractable condition and source of considerable discomfort and annoyance to the patient. It comprises of 1 percent of the total patients attending our hospital. It can affect one or multiple digits. Any finger may be involved. The initial change starts with loss of cuticle due to overexposure to water, caustics and detergents and thus the nail fold is separated from the nail where a little pouch is formed. These abnormal interstices are very difficult to keep dry. It remains moist for a long period after wet work and the moist grooves are thus invaded by fungi and bacteria which produce chronic inflammation and characteristic swelling of the nail folds. It is often accompanied by pruritus, pain and nail changes. This chronic process may have acute flare ups.


  Materials and Methods Top


This study of clinical and microbiological aspects of chronic paronychia had been carried out in the dermatological out-patients department of SSKM Hospital, Calcutta during a period of one year. Patients of all age groups with clinical manifestations of chronic paronychia were included. The cases were selected at random throughout the year. Detailed clinical examination findings and history obtained was noted.

Twenty five selected patients with purulent or cheesy discharge on pressure on nail folds were selected for culture. Where several nail folds were affected only the most affected nail was selected. Simultaneously, nutrient agar, blood agar and bromthymol blue lactose agar culture media were inoculated and incubated at 37 °C for 24 hours for bacterial growth. On the next day, colony characters were noted. Gram stain was done for identification. Then nutrient broth cultures were done incubating at 37 °C for 24 hours from where sugar tubes and biochemical tubes were inoculated to observe the biochemical reactions for identification and confirmation of species of bacteria.

For detection of fungus a part of discharge was examined direct under microscope in 10 percent KOH for presence of round or oval budding cells or short filaments. The remaining part was cultured in 2 tubes of Sabouraud's dextrose agar media plain and with antibiotic chloramphenicol (0.05 mgm/ml) and cycloheximide (0.05 mgm/ml) at pH 5.4 then incubated one in 37 0 sub C and the other in 22 ° C for 2 to 3 days usually for characteristic growth and discarded after 7 days if no growth was seen. Gram stain was done to see spherical or oval yeast cells with presence of occasional pseudomycelium. Then subculture in nutrient agar and reculture in cornmeal agar plate was done for formation of characteristic chlamydospore with germ tube.

Lastly, sugar fermentation reaction in inverted Durham's tube for formation of acid and gas was seen to identify different species of candida. Postprandial blood sugar was estimated in all patients.


  Results Top


The incidence of chronic paronychia was 1 percent, with peak in rainy season. It can occur at any age but 76 percent of the patients were between 21 to 50 years. Females were more commonly affected than the males, the ratio being 7:2. Sixty-four out of 100 patients were housewives and came from low and middle income groups. It can affect one or multiple digits but right ring finger (46) and right thumb (41) were mostly affected. Regarding nail changes, colours noted were brownish black (64 percent), black (20 percent) and no colour change in 16 percent. Transverse striations were seen in 79 cases, longitudinal in 1 case, no striation in 20 cases. Pitting was observed in 15 cases. Associated skin diseases were eczema (20) and candidiasis of palms and soles (11). Three cases were known diabetics and 2 cases of high blood sugar were revealed on routine examination. Two cases of chronic diarrhea and 1 case of peptic ulcer were among other systemic diseases which were associated. Bacteria found [Table - 1] were Staphylococcus aureus Scientific Name Search  (60 percent), Klebsiella aerogenes (16 percent),  Escherichia More Details coli (12 percent),  Pseudomonas aeruginosa Scientific Name Search 2 percent),  Proteus mirabilis Scientific Name Search  (8 percent) and nonpathogenic variety,  Staphylococcus epidermidis Scientific Name Search ercent). In very few cases more than one species were isolated. KOH (10 percent) preparation showed only spores in 13 cases, spores together with budding and filamentous hyphae in 5 cases and neither spore nor hyphae in 7 cases. Culture for fungus of above 25 cases revealed [Table - 2] Candida albicans in 16 cases and C.krusei, C.stellatoides, C.viswanathi, C.parapsilosis, C.tropicalis species in only 1 case each. No fungus was detected in 4 cases.


  Comments Top


In our study male-female ratio was 2:7. Leon [1] in his study of 201 cases found that 90 percent were females, 8.5 percent were children and 1.5 percent were males. In our study the incidence of males was higher (22 percent) and 50 percent of them were engaged in professions which necessitated wet macerating works. Seventy six percent of the patients were between 21 to 50 years of age. Esteves [2] found most of his patients in 30 to 60 years age group. Hellier [3] and Whittle et al [4] found 77 percent and 72 percent incidence respectively in the above age groups. The housewives particularly over-enthusiastic in wet works were predominantly the sufferers. The incidence of housewives in our study was 64 percent and in Hellier's [3] was 66 percent. Chronic paronychia is a disease of the low and middle income groups as 70 percent belonged to these groups in our series. According to Ganor and Pumpianski [5] the infected fingers were mostly the middle one of the dominant hand as because of its length it was easy to be traumatised and infected after defecation. But in our country the situation is different as we clean the part after defecation with left hand and still the right ring fingers were affected in 46 percent of cases. Nail changes were found almost in all cases of which transverse striation, pitting and hypertrophy were predominant and were possible due to inflammation of nail matrix. Chernosky, [6] Shellow and Koplon [7] and Zueheike [8] tried to attribute different colours of nails to different bacterial organisms which we failed to corroborate. Chronic paronychia is a very insidious process, average duration being 3.7 years, shortest was 3 months and longest being 30 years. Whittle et al [4] reported average duration of 20 years, the longest being 35 years. Of the associated skin diseases eczema, psoriasis, candidiasis of palms and soles, pemphigus vulgaris and hyperhidrosis were predominant. Impairment of peripheral blood flow was not seen in any of our patients. According to Stone [9] 9.5 percent of diabetic female patients over the age of 20 suffered from chronic paronychia as against 3.4 percent in contrast group. We found that 4 (5 percent) out of 78 female patients were diabetics and these 4 patients also gave history of doing far more macerating work. Out of 25 cases investigated for culture of fungus, 16 had candida albicans (64 percent). Different authors like Frain-Bell, [10] Whittle and Moffat, [4] Marten, [11] Stone and Mullins [9] sub and Ganor [5] found candida albicans in 70, 40, 97, 95 and 50 percent respectively and they all agreed like us that candida albicans was the major offender. Whittle and Moffat [4] in their series of 104 cases got other species of candida in 20 percent cases like that of ours. In 4 instances 16 percent culture yielded no growth and paronychia seemed to be of purely bacterial origin. Staphylococcus aureus was the predominant organism and was found in 60 percent cases on bacteriological examination. This high prevalence was also seen by Hellier, [3] sub Whittle and Moffat, [4] sub Samman [12] and they were of the opinion that nose is perhaps the main reservoir. Other bacteria found in this series were Klebsiella aerogenes (4), Escherichia coli (3), Pseudomonas aeruginosa (3), Proteus mirabilis (2), Staphylococcus epidermidis (1) and Streptococcus viridans (1). These are also found in normal intestinal flora and might infect nailfold being contaminated by stool. It is obvious from [Table - 1] that in 21 cases one single bacterium was isolated and in 4 cases double pathogens were found. It can be concluded from this study that chronic paronychia is due to mixed infection of bacteria and candida in 80 percent cases and purely bacterial infection in the remaining 20 percent.

 
  References Top

1.Leon R. Perionyxis due to Candida: Clinicostatistical and Mycological Study. M Menerva Dermatol 1965; 40: 348-56.  Back to cited text no. 1    
2.Esteves J. Pathogenesis and treatment of chronic paronychia. Dermatologica 1959; 119: 229.  Back to cited text no. 2  [PUBMED]  
3.Hellier F F. Chronic Paronychia. Br J Dermatol 1975; 90 : 77.  Back to cited text no. 3    
4.Whittle C H, Moffat J L, Davis R A. Paronychia and perionychia: Aetiological aspect. Br J Dermatol 1959; 71 : 1 - 11•.  Back to cited text no. 4    
5.Ganor S, Pumpianski R. Chronic paronychia and oral and vaginal candidal carriage. Mykosen 1970;13: 537-42.  Back to cited text no. 5  [PUBMED]  
6.Cherndsky M F, Dukes C O. Green nail­importance of Pseudomonas aeruginosa in onychia. Arch Dermatol 1963; 88 : 548 - 53.  Back to cited text no. 6    
7.Shellow WVR, Koplon BS. Green striped nail: Chromonychia due to Pseudomona aeruginosa. Arch Dermatol 1968; 97 : 149.  Back to cited text no. 7    
8.Zuehelke RL, Taylor WR. Black nail with proteus mirabilis. Arch Dermatol 1970; 102: 154.  Back to cited text no. 8    
9.Stone 0 J, Mullins F J. Incidence of chronic paronychia. JAMA 1963; 186: 71 -3.  Back to cited text no. 9    
10.Frain-Bell W. Chronic paronychia : Short review of 150 cases. Trans St. John's Hosp Derm Soc 1957; 38: 29.  Back to cited text no. 10    
11.Marten RH. Chronic paronychia. BrJ Dermatol 1959; 71 : 422 - 6.  Back to cited text no. 11  [PUBMED]  
12.Samman PD. The nails. In: Text-book of Dermatology, (Rook A, Wilkinson DS, Ebling FJG, eds), 2nd edn. Oxford : Blackwell Scientic publication, 1972; 1651.  Back to cited text no. 12    


    Tables

[Table - 1], [Table - 2]

This article has been cited by
1 Onycholysis caused by Candida krusei
Rao, S.D., Wavare, S., Patil, S.
Indian Journal of Medical Microbiology. 2004; 22(4): 258-259
[Pubmed]



 

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