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Eponychial Marsupialisation for Chronic Paronychia

31 citationsUpdated Oct 2026
Illustration: Eponychial Marsupialisation for Chronic Paronychia

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

Overview

Eponychial marsupialization is an effective surgical intervention for chronic paronychia, a condition characterized by maceration as the primary etiology [6]. This procedure is indicated for recalcitrant cases where conservative management fails, serving as an alternative to en bloc excision of the proximal nail fold [2]. The technique involves marsupialization of the eponychium, with or without nail plate removal, and has demonstrated high efficacy in curing this generally intractable condition [3]. While acute paronychial abscesses are typically managed operatively, no consensus exists regarding the optimal surgical technique for these acute presentations [16].

The procedure offers both functional and aesthetic benefits, with the gap between the proximal nail fold and nail plate healing and filling within 6–8 weeks to provide relief from symptoms [14]. Clinical outcomes indicate that chronic paronychia requires an average of 20.4 ± 18.32 days of therapy to reach the treatment endpoint [11]. Although Staphylococcus pyogenes and Candida albicans are frequently cultured from infected nail folds [13], antibiotics are not required in the postoperative phase following excision of uncomplicated paronychia in patients who are not at risk [7].

Alternative surgical options, such as the square flap technique, provide effective and safe treatment for refractory chronic paronychia with low risks of complications and recurrence [8]. This technique offers good prognosis during follow-up and optimal cosmetic results [10]. En bloc excision of the proximal nail fold remains a useful method for recalcitrant cases [5]. However, large prospective studies are needed to identify the best treatment regimen for both acute and chronic paronychia [4].

Anatomy & Pathophysiology

Etiology and Pathogenesis

Chronic paronychia is a distinct condition from acute paronychia [17]. The etiology of chronic paronychia is multifactorial [17] and the condition is considered a multiple process disease [6]. Maceration is the primary etiology of chronic paronychia [6]. In contrast, acute paronychia occurs after the disruption of a seal between the nail fold and the nail plate, complicated by the opportunistic entry of bacteria [17]. In acute paronychia, infection may continue under the eponychial fold and involve the opposite nail fold as a run around abscess [17]. Suboptimal treatment of acute paronychia can lead to deeper soft tissue infection, osteomyelitis, or chronic paronychia with or without permanent damage to the nail bed [17]. The basic mechanisms for paronychia in children are the same as those reported in adults [27].

Clinical Presentation and Demographics

Chronic paronychia commonly occurs in adult women [17] and is very common in adult females [27]. The condition is not uncommon in children [27]. The clinical course of chronic paronychia is indolent and has repeated episodes of inflammation, pain, and swelling [17]. Initial symptoms of acute paronychia include erythema and swelling of the unilateral nail fold [17].

Anatomical Considerations

The aim of surgical treatment for chronic paronychia is to cure the condition by exposing the inflamed germinal matrix to permit unrestricted drainage [17]. The dorsal integument of the distal phalanx is a unique cutaneous unit characterized by the presence of the nail bed with its matrix [45]. The anatomy and physiology of the nail must be understood for effective nail care [74].

Classification

Chronic paronychia is classified as a multifactorial condition induced and maintained by several causes [28]. It is a multiple process disease [6] and is generally considered an intractable condition [3]. The disease is not a type of onychomycosis but a variety of hand dermatitis caused by environmental exposure [22].

Etiology: The underlying cause is generally agreed to be prolonged exposure to (cold) water [25]. This exposure allows Candida and Pseudomonas species to act as opportunist pathogens [25]. Staphylococcus pyogenes and Candida albicans are frequently cultured from infected nail folds [13]. The mechanisms of infection, trauma, and prolonged immersion of the hands in water are not sufficient to explain the chronic forms of the disease [18].

Other Considerations: Treatment of chronic paronychia is difficult and frustrating [17].

Clinical Presentation

Chronic paronychia follows an indolent clinical course characterized by repeated episodes of inflammation, pain, and swelling [17]. The condition is multifactorial [17, 28] and functions as a multiple process disease where maceration serves as the primary etiology [6]. It is induced and maintained by several causes, most commonly representing a clinical variety of contact urticaria resulting from impairment of the epidermal barrier [28].

In pediatric patients, the sources of maceration, associated diseases, clinical appearances of the lesion, and patients' responses to symptoms differ from those observed in adults [27]. Chronic keratinaceous paronychia should be regarded as a potential complication of nail biting [29]. Atypical hand infections present diagnostic challenges due to their indolent nature and nonspecific symptoms, making them difficult to recognize and treat [40].

Investigations

Other Considerations: Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [35]. A careful physical examination is essential to direct care and future testing if indicated [31]. Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism [40].

Treatment

Non-Operative

Conservative management of chronic paronychia includes pharmacological and physical therapies. Oral fluconazole at a dose of 50 mg/day is both effective and safe for managing the condition [19]. Topical tacrolimus 0.1% ointment provides statistically significant improvement compared with emollient alone [77] and is considered an effective alternate treatment option [85]. Low-level laser therapy (LLLT) requires an average of 20.4 ± 18.32 days of therapy to reach the treatment endpoint [11]. Additionally, chemical sealing using cyanoacrylate glue allows the gap between the proximal nail fold and nail plate to heal and fill within 6–8 weeks, providing relief from chronic paronychia [14].

Operative

Indications: Surgical treatment is indicated to cure paronychia by exposing the inflamed germinal matrix to permit unrestricted drainage [17].

Surgical Approach / Technique: The procedure can be achieved by eponychial marsupialisation or en bloc excision of the proximal nail fold [17]. Simultaneous removal of the irregular nail plate has been proposed to improve clinical outcomes in the surgical treatment of chronic paronychia [17].

Other Considerations: In a cohort of twenty-eight consecutive fingers with chronic paronychia in twenty-five patients treated by the senior author, the average patient age was 44 ± 3 years, with a range of 21 to 67 [26].

Complications

Infection: Suboptimal treatment of acute paronychia can lead to deeper soft tissue infection [17]. This progression may further result in osteomyelitis [17].

Other Considerations: Inadequate management of acute paronychia can lead to chronic paronychia [17] and permanent damage to the nail bed [17].

Recovery

Light activity (weeks): The gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks following chemical sealing with cyanoacrylate glue [14].

Other Considerations: Antibiotics are not needed in the postoperative phase after excision of uncomplicated paronychia in patients who are not at risk [7]. Treatment response for paronychia is assessed by clinical grading using the morphologic six-point PSG scale [43]. The primary efficacy endpoint for paronychia treatment is defined as a two-grade reduction on the PSG scale, or a reduction to zero if nails involved were grade 1 at baseline [43]. Secondary efficacy endpoints for paronychia treatment include paronychia QoL responses, microbiologic responses, and safety [43]. Microbiological assessments for paronychia treatment involve bacterial culture and nail clipping with periodic acid-Schiff (PAS) staining for fungus obtained from the most severely affected nail [43]. Cultures and nail clippings for paronychia assessment are obtained from the same nail at baseline, first follow-up, and final study visit [43]. The HFS-14 questionnaire is used to assess quality of life in patients suffering from paronychia [43].

Key Evidence

  • [L4] Eponychial marsupialization is an effective means of treating chronic paronychia. [1] (10.1016/s0363-5023(10)80118-2)
  • [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. [2] (10.4103/0019-5154.123482)
  • [L4] The authors state that the eponychial marsupialization procedure has been highly effective in curing chronic paronychia, a generally intractable condition. [3] (10.1097/00006534-197607000-00011)
  • [L5] Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia. [4] (10.5435/jaaos-22-03-165)
  • [L2] En bloc excision of the proximal nail fold is a useful method in recalcitrant chronic paronychia. [5] (10.1111/j.1524-4725.2006.32079.x)
  • [L4] The authors feel that chronic paronychia is a multiple process disease and that maceration is the primary etiology. [6] (10.1001/archderm.1964.01590270141032)
  • [L2] The findings confirm that antibiotics are not needed in the postoperative phase after excision of uncomplicated paronychia and felon in patients who are not at risk. [7] (10.1016/j.hansur.2015.12.003)
  • [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. [8] (10.5935/scd1984-8773.2026180505)
  • [L5] The review provides a focused summary of management approaches, noting that early felons and paronychia may be managed with antibiotics alone, while more advanced infections require incision and drainage. [9] (10.1016/j.jemermed.2025.07.054)
  • [L4] This surgical technique can provide an alternative treatment for chronic paronychia, with good prognosis during follow up-period and optimal cosmetic results. [10] (10.1016/j.jaad.2016.02.1154)
  • [L4] Chronic paronychia required on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint. [11] (10.5978/islsm.10.133)
  • [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. [13] (10.1136/bmj.4.5730.257)
  • [L4] The gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks, providing relief from chronic paronychia. [14] (10.25259/csdm_132_2023)
  • [L5] While acute paronychial abscesses are generally treated operatively, there is no consensus on the best surgical technique. [16] (10.1016/j.jhsa.2011.11.021)
  • [L4] [17] (10.1097/bth.0b013e3181ec089e)
  • [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. [18] (10.1159/000255443)
  • [L4] These results show that 50 mg/day fluconazole is both effective and safe in the management of chronic paronychia. [19] (10.3109/09546639909056029)
  • [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. [22] (10.1067/mjd.2002.122191)
  • [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. [25] (10.1136/bmj.2.6200.1294-a)
  • [L5] [26] (10.1016/s0363-5023(10)80117-0)
  • [L4] [27] (10.1177/000992286800700213)
  • [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. [28] (10.5070/d32wb4g9wf)
  • [L5] Chronic keratinaceous paronychia should be regarded as a potential complication of nail biting. [29] (10.1136/bmj.280.6208.189-g)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [35] (10.1016/j.hcl.2020.03.002)
  • [L4] Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism. [40] (10.1016/j.jhsa.2025.09.023)
  • [L2] [43] (10.1007/s10637-019-00825-0)
  • [Paper] The anatomy and physiology of the nail must be understood for nail care to be effective. [74] (10.1016/s0894-1130(00)80018-6)
  • [L1] Patients with chronic paronychia applying tacrolimus 0.1% ointment presented statistically significant improvement when compared with those applying just emollient. [77] (10.1111/j.1365-2133.2008.08988.x)
  • [L2] Tacrolimus ointment is effective and should be considered as an alternate treatment option for chronic paronychia. [85] (10.1111/j.1365-2133.2010.09784.x)

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

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

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

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

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

[7] Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients. Hand Surgery and Rehabilitation. 2016. DOI: 10.1016/j.hansur.2015.12.003

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

[9] Management of Finger Felons and Paronychia: A Narrative Review. The Journal of Emergency Medicine. 2025. DOI: 10.1016/j.jemermed.2025.07.054

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

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

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

[14] 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

[16] Acute Paronychia. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.021

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

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

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

[22] 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

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

[26] Herpetic whitlow with bacterial abscess. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80117-0

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

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

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

[31] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[35] Imaging and Laboratory Workup for Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.002

[40] Atypical Hand Infections. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.09.023

[43] A randomized phase 2 trial of the efficacy and safety of a novel topical povidone-iodine formulation for Cancer therapy-associated Paronychia. Investigational New Drugs. 2019. DOI: 10.1007/s10637-019-00825-0

[45] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.

[74] Understanding the perionychium. Journal of Hand Therapy. 2000. DOI: 10.1016/s0894-1130(00)80018-6

[77] Efficacy and safety of tacrolimus ointment 0·1% vs. betamethasone 17-valerate 0·1% in the treatment of chronic paronychia: an unblinded randomized study. British Journal of Dermatology. 2009. DOI: 10.1111/j.1365-2133.2008.08988.x

[85] Efficacy and safety of tacrolimus ointment 0·1% vs. betamethasone 17-valerate 0·1% in the treatment of chronic paronychia: an unblinded randomized study. British Journal of Dermatology. 2010. DOI: 10.1111/j.1365-2133.2010.09784.x

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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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