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Eponychial Marsupialisation for Chronic Paronychia

32 citationsUpdated Aug 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Eponychial marsupialization is an effective means of treating chronic paronychia [1]. This procedure has been highly effective in curing chronic paronychia, a generally intractable condition [2]. Surgical treatment for recalcitrant chronic paronychia may include en bloc excision of the proximal nail fold or eponychial marsupialization, with or without nail plate removal [4]. En bloc excision of the proximal nail fold is a useful method in recalcitrant chronic paronychia [9].

Alternative surgical options include the square flap technique, which is an effective and safe option for the treatment of refractory chronic paronychia, providing both functional and aesthetic improvement with a low risk of complications and recurrence [11]. The square flap technique can provide an alternative treatment for chronic paronychia, with good prognosis during follow-up period and optimal cosmetic results [6]. Non-surgical management includes chemical sealing of the proximal nail fold with cyanoacrylate glue, which allows the gap between the proximal nail fold and nail plate to heal and fill up within 6–8 weeks, providing relief from chronic paronychia [7]. Additionally, chronic paronychia required on average 20.4 ± 18.32 days of therapy with LLLT to reach the treatment endpoint [5].

The microbiological profile of the condition includes Staphylococcus pyogenes and Candida albicans, which are frequently cultured from infected nail folds in chronic paronychia [8]. Despite these established treatments, large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia [3].

Anatomy & Pathophysiology

Chronic paronychia represents a form of chronic hand infection [40]. These infections are uncommon and necessitate a high index of suspicion for early diagnosis [40]. Most hand infections result from neglected minor wounds [34]. The hand infections category encompasses a diverse array of entities with potential for serious morbidity [35] and is associated with a high rate of complications that are often difficult to manage [33].

Microorganism Classification: Chronic hand infections are grouped by microorganism into bacterial (mycobacterial and others), fungal, and viral types [40]. Risk Factors: HIV infection increases the risk of developing a hand infection but does not lead to an increased risk of revision surgery or ablation [38]. Pediatric Considerations: Pediatric hand infections involve unique environments and characteristics, including the frequency of fingers in mouths, open growth plates, and typically more robust circulation with fewer systemic comorbidities [32].

The surface, gross, and microscopic anatomy of the distal digit facilitates surgical procedures in the nail unit with minimal residual impact [31]. Many nail bed injuries are preventable, and targeted prevention strategies should be considered [39].

Classification

Surgical Modalities: En bloc excision of the proximal nail fold or eponychial marsupialization, with or without nail plate removal, constitutes surgical treatment for recalcitrant chronic paronychia [4]. The square flap technique offers an alternative with good prognosis during follow-up and optimal cosmetic results [6]. The Swiss Roll technique is recommended for both severe acute and chronic paronychia, with no contraindications identified [15].

Etiologic Classification: Chronic paronychia is a multifactorial condition where maceration serves as the primary etiology [13]. It represents a clinical variety of contact urticaria resulting from impairment of the epidermal barrier [19] and is not a type of onychomycosis but a variety of hand dermatitis caused by environmental exposure [30]. The mechanisms of infection, trauma, and prolonged immersion of the hands in water are not sufficient to explain the chronic forms of paronychia [12].

Outcome Metrics: Chronic paronychia required an average of 20.4 ± 18.32 days of therapy to reach the treatment endpoint [5].

Allen’s Classification: This system categorizes fingertip lesions into four types: type I (only pulp involved), type II (loss of pulp and portion of nail matrix/small part of bone), type III (bone loss), and type IV (eponychium involved along with pulp, nail, and distal phalanx) [29].

Other Considerations: Eponychium flap reconstruction is contraindicated for injuries with crushing of the eponychial fold [29]. It can be carried out alone or in combination with a volar advancement flap for injuries with loss of more than 50% of the size of the nail [29].

Clinical Presentation

The etiology of chronic paronychia is multifactorial, with prolonged exposure to (cold) water allowing Candida and Pseudomonas species to act as opportunist pathogens [18]. Maceration is considered the primary etiology in this multiple process disease [13]. In pediatric populations, the condition is predominantly associated with thumb-sucking, which causes maceration and creates a pocket for organisms like Candida albicans [28]. Chronic keratinaceous paronychia should be regarded as a potential complication of nail biting [27].

Persistent, active inflammation, compromised vasculature, poor hand hygiene, poor healing, and a reluctance to seek treatment may allow atypical chronic sterile paronychia to evolve and erode into the joint space [21].

Diagnosis requires distinguishing infectious from noninfectious causes, as noninfectious etiologies can result in identical nail changes [24]. Objective examination findings and appropriate histologic analysis help distinguish onychomycosis from lichen planus, psoriasis, melanoma, squamous cell carcinoma, posttraumatic changes, and yellow nail syndrome [24]. The diagnosis of onychomycosis may be obvious by physical examination but should be confirmed by objective data before treatment is considered [24]. Direct microscopic examination of a potassium hydroxide preparation can identify the presence of fungi in a nail sample [24].

Clinical presentation of onychomycosis varies by subtype:

Superficial white onychomycosis: Direct involvement of the surface of the nail plate; this is the most common presentation in the pediatric population [24].

Proximal subungual onychomycosis: Originates from the proximal nail fold, presents in the proximal nail, always involves the nail plate, and is seen as leukonychia (white areas within the nail plate) [24].

Total dystrophic onychomycosis: Involves the entire nail and destroys its natural architecture, commonly reflecting the progression of any form of onychomycosis with Trichophyton rubrum as the most common causative agent [24].

Distal (and lateral) subungual onychomycosis: Originates from the surrounding skin and can involve the nail plate, nail bed, and hyponychium [24].

Treatment

Non-Operative

A simple procedure without nail removal should be tried first in almost every case, as many patients may be cured without recourse to nail removal [22]. Fluconazole 50 mg/day therapy is both effective and safe in the management of chronic paronychia [14].

Operative

Surgical Approach / Technique: Chronic paronychia required on average 20.4 ± 18.32 days of laser therapy to reach the treatment endpoint [5].

Recovery

Surgical management for recalcitrant cases involves en bloc excision of the proximal nail fold or eponychial marsupialization, performed with or without nail plate removal [4].

Light activity (weeks): The gap between the proximal nail fold and nail plate heals and fills within 6–8 weeks, providing relief from chronic paronychia [7].

Full activity (months): Evidence does not specify a distinct timeframe for full activity return beyond the initial healing period.

Complete recovery / outcome plateau (months): The 6–8 week healing period provides relief from chronic paronychia [7].

Rehabilitation protocol: No specific rehabilitation protocol, immobilisation duration, or weight-bearing progression is specified in the provided evidence.

Functional milestones: No validated PROM trajectories or outcome-measure benchmarks are specified in the provided evidence.

Other Considerations: The available evidence includes a report on 26 patients treated for paronychia granulomatosa [10].

Key Evidence

  • [L4] Eponychial marsupialization is an effective means of treating chronic paronychia. [1] (10.1016/s0363-5023(10)80118-2)
  • [L4] The authors state that the eponychial marsupialization procedure has been highly effective in curing chronic paronychia, a generally intractable condition. [2] (10.1097/00006534-197607000-00011)
  • [L5] Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia. [3] (10.5435/jaaos-22-03-165)
  • [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. [4] (10.4103/0019-5154.123482)
  • [L4] Chronic paronychia required on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint. [5] (10.5978/islsm.10.133)
  • [L4] This surgical technique can provide an alternative treatment for chronic paronychia, with good prognosis during follow up-period and optimal cosmetic results. [6] (10.1016/j.jaad.2016.02.1154)
  • [L4] The gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks, providing relief from chronic paronychia. [7] (10.25259/csdm_132_2023)
  • [L5] The paper reviews the aetiology and treatment of chronic paronychia, noting that Staphylococcus pyogenes and Candida albicans are frequently cultured from infected nail folds. [8] (10.1136/bmj.4.5730.257)
  • [L2] En bloc excision of the proximal nail fold is a useful method in recalcitrant chronic paronychia. [9] (10.1111/j.1524-4725.2006.32079.x)
  • [L4] The study reports on 26 patients treated for paronychia granulomatosa. [10] (10.2340/000155555319320)
  • [L5] The square flap technique is an effective and safe option for the treatment of refractory chronic paronychia, providing both functional and aesthetic improvement with a low risk of complications and recurrence. [11] (10.5935/scd1984-8773.2026180505)
  • [L4] The author describes the principal clinical characteristics of paronychia and reviews its pathogenesis, stressing the fact that the mechanisms of infection, trauma and prolonged immersion of the hands in water, are not sufficient to explain the chronic forms of the disease. [12] (10.1159/000255443)
  • [L4] The authors feel that chronic paronychia is a multiple process disease and that maceration is the primary etiology. [13] (10.1001/archderm.1964.01590270141032)
  • [L4] These results show that 50 mg/day fluconazole is both effective and safe in the management of chronic paronychia. [14] (10.3109/09546639909056029)
  • [L4] [15] (10.1097/bth.0b013e3181ec089e)
  • [L5] The underlying cause of chronic paronychia is generally agreed to be prolonged exposure to (cold) water, allowing Candida and Pseudomonas species to act as opportunist pathogens. [18] (10.1136/bmj.2.6200.1294-a)
  • [L5] Chronic paronychia is a multifactorial condition induced and maintained by several causes, most commonly representing a clinical variety of contact urticaria resulting from impairment of the epidermal barrier. [19] (10.5070/d32wb4g9wf)
  • [L5] The combination of persistent, active inflammation, compromised vasculature, poor hand hygiene, poor healing and a reluctance to seek treatment may well have allowed the paronychia to evolve and erode into the joint space. [21] (10.1111/j.1440-0960.2012.00967.x)
  • [L5] The author believes that this simple procedure should be tried first in almost every case, as many patients may be cured without recourse to nail removal. [22] (10.1056/nejm193412062112313)
  • [L5] [24] (10.1016/j.jhsa.2013.11.017)
  • [L5] Chronic keratinaceous paronychia should be regarded as a potential complication of nail biting. [27] (10.1136/bmj.280.6208.189-g)
  • [L4] Chronic paronychia in children is predominantly associated with thumb-sucking, which causes maceration and creates a pocket for organisms like Candida albicans. [28] (10.1177/000992286800700213)
  • [L4] [29] (10.1016/j.jhsg.2025.02.009)
  • [L1] The results support the view that chronic paronychia is not a type of onychomycosis but a variety of hand dermatitis caused by environmental exposure. [30] (10.1067/mjd.2002.122191)
  • [L5] This review discusses the surface, gross, and microscopic anatomy of the distal digit to facilitate surgical procedures in the nail unit with minimal residual impact. [31] (10.1097/00042728-200103000-00009)
  • [L5] Although many management principles are the same in pediatric and adult patients, physicians should bear in mind the unique environments and characteristics of the pediatric hand, including the frequency of fingers in mouths, open growth plates, and typically more robust circulation with fewer systemic comorbidities. [32] (10.1016/j.hcl.2020.03.012)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [33] (10.1016/j.hcl.2020.03.010)
  • [L4] Most hand infections are the result of minor wounds that have been neglected. [34] (10.1016/j.ijid.2005.06.009)
  • [L5] Hand infections include a diverse array of entities with potential for serious morbidity. [35] (10.1016/j.jhsa.2011.05.035)
  • [L3] HIV infection increased the risk of developing a hand infection but did not lead to an increased risk of revision surgery or ablation. [38] (10.1177/1753193420977791)
  • [L4] Many of these injuries are preventable, and targeted prevention strategies should be considered. [39] (10.1177/1753193419826465)
  • [L5] Chronic hand infections are uncommon and require a high index of suspicion for early diagnosis; they are grouped by microorganism into bacterial (mycobacterial and others), fungal, and viral types, with specific presentations and treatments emphasized for each. [40] (10.1016/j.jhsa.2014.04.003)

See Also

References

[1] Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80118-2

[2] SURGICAL CURE OF CHRONIC PARONYCHIA BY EPONYCHIAL MARSUPIALIZATION. Plastic and Reconstructive Surgery. 1976. DOI: 10.1097/00006534-197607000-00011

[3] Acute and Chronic Paronychia of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-03-165

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

[5] TREATMENT OF NAIL DISORDERS WITH LLLT (2) CHRONIC PARONYCHIA AND INGROWN NAIL. LASER THERAPY. 1998. DOI: 10.5978/islsm.10.133

[6] Chronic paronychia treatment: Square flap technique. Journal of the American Academy of Dermatology. 2016. DOI: 10.1016/j.jaad.2016.02.1154

[7] Chemical sealing of proximal nail fold with cyanoacrylate glue for accelerated regeneration of nail cuticle as a treatment of chronic paronychia. Cosmoderma. 2023. DOI: 10.25259/csdm_132_2023

[8] Problems of chronic paronychia.. BMJ. 1970. DOI: 10.1136/bmj.4.5730.257

[9] En Bloc Excision of Proximal Nail Fold for Treatment of Chronic Paronychia. Dermatologic Surgery. 2006. DOI: 10.1111/j.1524-4725.2006.32079.x

[10] Surgical treatment of paronychia granulomatosa hallucis. Acta Dermato-Venereologica. 1975. DOI: 10.2340/000155555319320

[11] Exuberant chronic paronychia: a surgical approach using the square flap technique. Surgical & Cosmetic Dermatology. 2026. DOI: 10.5935/scd1984-8773.2026180505

[12] Pathogenesis and Treatment of Chronic Paronychia. Dermatologica. 2009. DOI: 10.1159/000255443

[13] Experimental Studies on Chronic Paronychia. Archives of Dermatology. 1964. DOI: 10.1001/archderm.1964.01590270141032

[14] Fluconazole 50 mg/day therapy in the management of chronic paronychia. Journal of Dermatological Treatment. 1999. DOI: 10.3109/09546639909056029

[15] Swiss Roll Technique for Treatment of Paronychia. Techniques in Hand & Upper Extremity Surgery. 2011. DOI: 10.1097/bth.0b013e3181ec089e

[18] Treatment of chronic paronychia. BMJ. 1979. DOI: 10.1136/bmj.2.6200.1294-a

[19] Controversy: the role of yeasts in chronic paronychia: pro. Dermatology Online Journal. 2003. DOI: 10.5070/d32wb4g9wf

[21] Atypical chronic sterile paronychia leading to tissue and joint space destruction in a patient with thromboangiitis obliterans. Australasian Journal of Dermatology. 2012. DOI: 10.1111/j.1440-0960.2012.00967.x

[22] Note on the Treatment of Paronychia. New England Journal of Medicine. 1934. DOI: 10.1056/nejm193412062112313

[24] Fungal Nail Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.11.017

[27] Points: Treatment of chronic paronychia. BMJ. 1980. DOI: 10.1136/bmj.280.6208.189-g

[28] Chronic Paronychia in Children. Clinical Pediatrics. 1968. DOI: 10.1177/000992286800700213

[29] Chronic Posttraumatic Nail Reconstruction with an Eponychium Flap: Technique Description and Case Series. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.02.009

[30] Topical steroids versus systemic antifungals in the treatment of chronic paronychia: An open, randomized double-blind and double dummy study. Journal of the American Academy of Dermatology. 2002. DOI: 10.1067/mjd.2002.122191

[31] Surgical Anatomy of the Nail Unit. Dermatologic Surgery. 2001. DOI: 10.1097/00042728-200103000-00009

[32] Pediatric Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.012

[33] Complications of Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.010

[34] Epidemiology of bacterial hand infections. International Journal of Infectious Diseases. 2006. DOI: 10.1016/j.ijid.2005.06.009

[35] Hand Infections. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.035

[38] Factors affecting suboptimal outcomes in hand infections. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420977791

[39] Experience of nail bed injuries at a tertiary hand trauma unit: a 12-month review and cost analysis. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419826465

[40] Chronic Hand Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.003

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a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

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