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Paronychia (Infection Beside the Nail)

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Updated Sep 20266 citations

What you're feeling

Paronychia means infection or inflammation in the skin beside or behind your fingernail. It comes in two forms. The acute form builds over several days: the skin fold next to your nail becomes red, swollen and tender, and the pain steadily gets worse. Pus may collect in that fold, but not under the nail itself. The redness stays near the fingertip and does not spread past the last joint of the finger.

The chronic form is much slower. It develops over many weeks or years, and the swelling and redness are usually milder than with the acute type. The skin fold at the back of the nail may lift away from the nail, leaving a small pocket that holds moisture. That pocket lets germs such as Candida (a yeast) and other organisms thrive. Symptoms that come and go over more than 6 weeks point to the chronic form, and flare-ups often follow time with your hands in water.

Daily tasks that keep your hands wet or dirty become the hardest part. Washing up, handwashing, cleaning, hairdressing or any work where your fingers are soaked again and again can set symptoms off. Damage to the cuticle from nail biting, manicuring, or contact with irritating substances breaks the skin's natural seal and lets irritants in. Over time the nail itself may change: ridges, grooves, discolouration or a rounded shape can appear, and a new healthy cuticle may fail to form.

If the infection is left untreated for a long time, it can wear deeper and reach the joint at the fingertip. That is why ongoing symptoms deserve a proper look rather than waiting for them to settle on their own.

What's actually happening

Your nail sits in a snug groove of skin called the nail fold. The cuticle is the thin seal where that fold meets the nail. When the seal breaks, through a hangnail, a manicure, nail biting or repeated soaking, germs get in underneath and set up an infection in the fold.

The acute form is a straightforward skin infection, usually from bacteria such as Staphylococcus aureus. Pus builds up in the tight space beside the nail, which is why the swelling and throbbing feel so intense. If it is ignored, the pus can track under the nail or around to the other side.

The chronic form works differently. Damage to the cuticle leaves a small pocket behind the nail that holds moisture, a bit like a damp gap under a loose tile where mould keeps returning. Yeast and other organisms settle in that pocket and keep the inflammation simmering. The pocket also stops a healthy new cuticle from forming, so the seal never repairs itself and the cycle repeats. That is why symptoms flare every time your hands are in water for a while.

Most of these infections start from a small wound that was left alone rather than cleaned and protected. If they are treated early, they usually settle without trouble. Left too long, the infection can spread under the nail, deform the way the nail grows, or reach deeper structures of the finger such as the tendon sheath or the bone.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. At your visit we take a history, examine the finger and arrange imaging only if it is needed.

Most acute infections settle without an operation. If there is no pus under the nail or in the nail fold, the usual treatment is antibiotic tablets, often with warm salt-water soaks at home. The warmth can help any hidden pus drain on its own. Caught early, an infection can sometimes be stopped within a few days without removing any nail. For the chronic form, caring for the nail folds matters more than any cream or tablet: keeping the hands dry, protecting the cuticle and avoiding long soaks do much of the work. A simple office procedure can lift the cuticle and place a small sterile rubber ribbon under it, which lets early infections settle without removing the nail. Where the gap behind the nail has opened up, sealing it with a medical glue (a cyanoacrylate, the same family as skin glues) lets it heal and fill in within 6-8 weeks.

If an abscess has formed, we may need to release it. That means a small cut in the skin fold beside the nail, or removing a strip of nail to let the pus out. For severe infections, a heated wire can be used to burn small holes through the nail so pus can drain. For chronic paronychia that will not settle with skin care alone, a minor procedure called marsupialisation removes the wedge of swollen tissue that keeps the pocket open, letting a healthy new cuticle form. These procedures are done under local anaesthetic and take only a short time. Most people go home the same day.

Whichever path we take, the aim is the same: drain any pus, calm the inflammation and give the nail fold the chance to rebuild its natural seal. We will talk through the options with you and decide together which suits your hand, your work and how long the problem has been there.

What to expect

Most acute infections settle within a few days once they are treated early. The swelling and tenderness ease, and the skin fold closes back over the nail. If pus has built up, draining it usually brings relief quickly, and the finger returns to normal as the infection clears.

The chronic form moves more slowly. It tends to come and go, flaring whenever your hands sit in water for a while. With steady care of the nail folds, keeping them dry and protecting the cuticle, the inflammation settles over weeks rather than days. The care you give your hands matters more than any cream or tablet. Where the gap behind the nail has opened up and is sealed with medical glue, it heals and fills in within 6-8 weeks. For stubborn chronic cases that need a minor procedure to remove the swollen tissue, a healthy new cuticle can form in its place, and the seal repairs itself.

If it is left alone, the outlook is less predictable. An untreated infection can spread under the nail, change the way the nail grows, or wear deeper into the finger. The nail may stay ridged, grooved or discoloured even after the infection settles. That is why symptoms lasting beyond 6 weeks deserve a proper look rather than waiting.

Recovery feels different for each form. With the acute type, you can expect soreness for a few days, then steady improvement. With the chronic type, expect gradual change: the flare-ups become less frequent, the skin fold settles down, and over the following weeks a new cuticle grows in to protect the nail again. Keeping your hands dry and out of prolonged soaks during this time gives the fold its chance to heal.

When to see someone

See your GP if the skin fold beside your nail has been red, swollen and painful for more than a few days, or if pus is collecting there. Ask for a specialist review if symptoms keep flaring for more than 6 weeks, especially when your hands are in water often, or if the nail itself has changed shape or colour. Go to an emergency department if the redness or swelling spreads up past the last joint of the finger, if the finger becomes hot and rapidly more painful, or if you feel feverish or unwell. These signs mean the infection is moving beyond the nail fold and needs same-day assessment.

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. Paronychia is worth the extra reading because one word covers two conditions that behave differently, respond to opposite treatments, and are routinely confused, and because the surgical answer for the chronic form is older, simpler and better supported than most people expect.

Two conditions, one name

Acute paronychia is a bacterial infection of the nail fold, most often Staphylococcus aureus, developing over 24 to 48 hours after the seal between nail and skin is breached [1]. It is red, hot, tense and disproportionately painful, and it forms pus.

Chronic paronychia, by convention lasting beyond six weeks, is not primarily an infection at all. It is an inflammatory dermatitis of the nail fold driven by repeated wet exposure and irritants, in which loss of the cuticle seal allows further irritant entry, producing a cycle that sustains itself [2]. Candida is frequently cultured from these folds, which is precisely why the condition was long treated as a fungal infection, but its presence is better understood as colonisation of an already-damaged fold than as the cause.

The trial that reframed the chronic form

The evidence that settles this is a randomised, double-blind, double-dummy trial comparing a topical steroid (methylprednisolone aceponate) against two systemic antifungals. Of 48 nails treated with the topical steroid, 41 were improved or cured, against 30 of 57 on terbinafine and 29 of 64 on itraconazole, a statistically significant advantage to the steroid [3].

The same trial contains the more decisive observation. Candida presence was not strictly linked to disease activity, and eradicating Candida was associated with clinical cure in only 2 of the 18 patients who carried it at baseline [3].

That is hard to reconcile with a fungal aetiology and easy to reconcile with an inflammatory one: the yeast is a passenger in a damaged fold, not the driver. It reframes the condition as a barrier problem: the cuticle is the seal, wet work destroys it, the fold swells, the swollen fold cannot re-seal, and organisms colonise the gap. Treating the colonisers leaves the mechanism untouched.

The practical corollary is unglamorous and is the part patients most often skip: the single most effective intervention is keeping the hands dry and out of irritants. Gloves outperform prescriptions here.

Acute paronychia: drainage, and how much to disturb

Once pus has formed, antibiotics alone will not clear it, the collection has to be released [1]. The traditional approach lifts the nail fold off the nail plate to decompress the abscess, removing part of the nail where pus has tracked beneath it.

A nail-preserving alternative is the Swiss roll technique, in which the nail fold is elevated and rolled back over a suture rather than incised or excised, held for a few days and then unrolled [4]. The attraction is that it drains a collection that has spread across the fold without sacrificing nail plate or nail fold, which matters where the alternative would be a wide incision.

The general principle across both is that the incision should decompress the fold rather than enter the pulp of the finger, since the pulp is a separate compartment and opening it converts a straightforward paronychia into a more troublesome wound.

Eponychial marsupialisation

For chronic paronychia that has not settled, the operation is one described in 1976 and essentially unchanged since.

Keyser and Eaton's procedure removes a crescent of the thickened proximal nail fold, taking the inflamed tissue while stopping short of the germinal matrix, and leaves the defect open to heal by contraction, which draws the fold back down onto the nail plate and restores the seal the disease destroyed [5].

The anatomy is what makes the margin critical. Beneath the cuticle sits a two-to-three-millimetre cul-de-sac of germinal matrix that produces the nail plate, and the subcutaneous layer over it governs the nail's surface. Disturb that layer, by infection, pressure or trauma, and nail production is deranged in proportion: brief episodes give transverse ridges, long-standing disease gives the longitudinal grooving and thickening that characterises chronic paronychia [5].

So sparing the germinal matrix is what prevents a permanent nail deformity, and leaving the wound open is what produces the contraction that reseals the fold, closing it would defeat the purpose.

The refinement that removed the recurrences

The most useful piece of outcome data is a small series with a clear internal comparison. As reported, fingers with nail irregularities treated by marsupialisation alone went on to recur in a minority of cases, whereas a subsequent group of fingers with nail irregularities treated by marsupialisation plus removal of the nail plate did not; fingers without nail irregularities healed with marsupialisation alone [6].

The series is small and sequential rather than randomised, so this is a signal rather than a proof — and the full text was not available to us, so the figures above are as summarised in the secondary literature rather than read from the paper. But it gives a concrete intraoperative rule: an irregular or ridged nail is evidence that the disease has already involved the matrix beneath, and in that finger the nail plate should come off as well. A normal-looking nail can be left.

That is an unusually actionable finding for a condition this common, and it is the reason the state of the nail plate, not just the fold, is worth examining before deciding on the operation.

Reviewed by AI synthesis (v2) — pending human review · 19 August 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading
  1. Ritting AW, O'Malley MP, Rodner CM. Acute paronychia. J Hand Surg Am. 2012;37(5):1068-70.
  2. Shafritz AB, Coppage JM. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014;22(3):165-74.
  3. Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002;47(1):73-6.
  4. Pabari A, Iyer S, Khoo CTK. Swiss roll technique for treatment of paronychia. Tech Hand Up Extrem Surg. 2011;15(2):75-7.
  5. Keyser JJ, Eaton RG. Surgical cure of chronic paronychia by eponychial marsupialization. Plast Reconstr Surg. 1976;58(1):66-70.
  6. Bednar MS, Lane LB. Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia. J Hand Surg Am. 1991;16(2):314-7.
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Surgical treatment for recalcitrant chronic paronychia may include en bloc excision of the proximal nail fold [1].
  • Surgical treatment for recalcitrant chronic paronychia may include eponychial marsupialization [1].
  • Surgical treatment for recalcitrant chronic paronychia may involve nail plate removal [1].
  • Each lesion studied in the 1962 Archives of Dermatology report had Candida albicans involvement with mycelium in the outer epidermis [2].
  • The lesions studied in the 1962 Archives of Dermatology report showed no involvement of the dermis by Candida albicans [2].
  • Candida albicans was recovered in approximately 15% of paronychia cases in the 1993 Journal of Hand Surgery study [3].

Anatomy & Pathophysiology

  • Chronic paronychia lesions exhibit Candida albicans involvement with mycelium present in the outer epidermis [2].
  • Chronic paronychia lesions do not involve the dermis [2].
  • Candida albicans was recovered in approximately 15% of paronychia cases in a study of mixed infections [3].

Classification

  • Chronic paronychia may be recalcitrant, requiring surgical treatment in such cases [1].
  • Surgical treatment for recalcitrant chronic paronychia includes en bloc excision of the proximal nail fold [1].
  • Surgical treatment for recalcitrant chronic paronychia includes eponychial marsupialization [1].
  • Each lesion of chronic paronychia studied had Candida albicans involvement with mycelium in the outer epidermis [2].
  • Lesions of chronic paronychia studied had no involvement of the dermis by Candida albicans [2].
  • Candida albicans was recovered in about 15% of paronychia cases in a study of mixed infections [3].

Clinical Presentation

  • Each lesion studied in the 1962 Archives of Dermatology study had Candida albicans involvement [2].
  • Lesions studied in the 1962 Archives of Dermatology study showed mycelium in the outer epidermis [2].
  • Lesions studied in the 1962 Archives of Dermatology study showed no involvement of the dermis [2].
  • Candida albicans was recovered in about 15% of cases in the 1993 Journal of Hand Surgery study [3].

Investigations

  • Chronic paronychia lesions studied in 1962 showed Candida albicans involvement with mycelium in the outer epidermis but no involvement of the dermis [2].
  • Candida albicans was recovered in about 15% of paronychia cases in a 1993 study [3].

Treatment

  • Surgical treatment for recalcitrant chronic paronychia may be performed with or without nail plate removal [1].
  • Chronic paronychia lesions studied in 1962 showed Candida albicans involvement with mycelium in the outer epidermis [2].
  • Chronic paronychia lesions studied in 1962 showed no involvement of the dermis by Candida albicans [2].
  • Candida albicans was recovered in approximately 15% of paronychia cases in a 1993 study [3].

Complications

  • Surgical treatment for recalcitrant chronic paronychia may involve en bloc excision of the proximal nail fold [1].
  • Surgical treatment for recalcitrant chronic paronychia may involve eponychial marsupialization [1].
  • Surgical treatment for recalcitrant chronic paronychia may include nail plate removal [1].

Recovery

  • Each lesion studied in the 1962 Archives of Dermatology study had Candida albicans involvement with mycelium in the outer epidermis [2].
  • The lesions studied in the 1962 Archives of Dermatology study showed no involvement of the dermis by Candida albicans [2].

Key Evidence

  • [L4] In recalcitrant cases, surgical treatment may be resorted to, which includes en bloc excision of the proximal nail fold or an eponychial marsupialization, with or without nail plate removal. [1] (10.4103/0019-5154.123482)
  • [L4] Each lesion studied had C. albicans involvement with mycelium in the outer epidermis but no involvement of the dermis. [2] (10.1001/archderm.1962.01590090066015)
  • [L4] Candida albicans was recovered in about 15% of the cases. [3] (10.1016/0266-7681(93)90063-l)

References

[1] Management of chronic paronychia. Indian Journal of Dermatology. 2014. DOI: 10.4103/0019-5154.123482

[2] Chronic Paronychia. Archives of Dermatology. 1962. DOI: 10.1001/archderm.1962.01590090066015

[3] Paronychia: a Mixed Infection. Journal of Hand Surgery. 1993. DOI: 10.1016/0266-7681(93)90063-l

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