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Paronychia (Infection Beside the Nail)

39 citationsUpdated Sep 2026

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

Overview

Paronychia is an infection of the nail fold, with Staphylococcus pyogenes and Candida albicans frequently cultured from affected tissue in chronic cases [1]. Chronic keratinaceous paronychia should be regarded as a potential complication of nail biting [2]. While Candida is often isolated, its eradication was not associated with clinical cure in most patients, indicating that it acts primarily as a colonizer of the proximal nail fold rather than the sole pathogenic agent [8].

Management prioritizes conservative measures, as a simple procedure should be tried first in almost every case because many patients may be cured without recourse to nail removal [6]. In a small number of patients treated for chronic paronychia, all improved at the same rate, probably because the care of the nail folds is more important than the medication applied [31]. For recalcitrant cases, en bloc excision of the proximal nail fold is a useful method [3]. Alternative interventions include chemical sealing with cyanoacrylate glue, where the gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks, providing relief from chronic paronychia [5]. Low-level laser therapy has also been utilized, with chronic paronychia requiring on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint [12]. Additionally, fifty-nine patients with proved monilial paronychia were treated with the nail polish sealer method [20].

Anatomy & Pathophysiology

Definition and Epidemiology

Paronychia is defined as an inflammation of the tissue surrounding the nail plate [9] and constitutes an infection of the epidermis bordering the nail [27]. In the United States, it is the most common hand infection, representing approximately 35% of all hand infections [27]. The condition affects women more frequently than men, with a female-to-male ratio of 3:1 [27]. Chronic paronychia almost exclusively affects adult women [10]. Most hand infections result from minor wounds that have been neglected [62].

Etiology and Pathogenesis

Acute paronychia is usually of streptococcal or staphylococcal origin, arising from a "hangnail" or trauma [9]. Staphylococcus aureus is the most commonly cultured organism in acute cases [27]. Localized trauma commonly precipitates the condition by providing a portal of entry for bacteria [27]. In chronic paronychia, the initial step is mechanical or chemical trauma that produces cuticle damage [10]. Cuticle injury can result from manicuring, occupational trauma, frequent handwashing, continuous exposure to water, and/or irritative compounds [10]. When the cuticle is damaged or lost, the epidermal barrier of the proximal nail fold is destroyed, exposing the tissue to environmental hazards [10]. Irritants and allergens may then penetrate the proximal nail fold to produce an inflammatory reaction of the nail fold and nail matrix [10]. This inflammatory reaction interferes with normal nail growth and the formation of a new cuticle [10]. Accumulating evidence indicates that chronic paronychia represents a clinical variety of contact urticaria in most cases [10]. In children, thumb-sucking is the most frequent predisposing factor [9]. Immunosuppressive states and systemic diseases such as diabetes can alter the causative organisms and the intensity of treatment required [27].

Anatomical and Histological Changes

Chronic paronychia consists of a pocket that holds moisture and allows the survival of many different organisms [9]. The condition involves an anatomic deformity of rounding out and retraction of the posterior nail fold due to foreign material in the dermis [9]. This dermal change assures the continuing presence of the moisture pocket [9]. In adults, chronic paronychia often begins with a swelling and separation of the lateral nail fold from the side of the nail [9]. In children, lesions are generally prominent with total involvement of the posterior nail fold [9]. The lesion appears as a marked rounding out and retraction of the posterior nail fold, often with thick pustular material expressed from the pocket [9]. Chronic monilial disease usually localizes at sites of pre-existing defects [9]. Monilia contribute to the disease process by irritation on the surface and by penetration of debris into the dermis [9]. This debris stimulates chronic inflammation which often aggravates the original defect [9].

Experimental evidence clarifies the pathogenic mechanism. Sterile maceration of the posterior nail fold for three to six months did not produce the changes of chronic paronychia [47]. Strong and weak concentrations of primary irritants produced erythema and ridging of the nail without the rounding out of the fold [47]. The addition of hemolytic streptococci, Proteus mirabilis, Proteus morganii, E. coli, and Pseudomonas aeruginosa to occluded nail folds sped maceration but did not produce a final lesion significantly different from simple maceration [47]. Conversely, the retraction and rounding out phenomenon was repeatedly reproduced when C. albicans was added to the fold and occluded for 30 days [47]. Maceration of the posterior nail fold allows the passage of foreign material into the dermis of the fold, inciting a chronic inflammatory reaction [47]. It is postulated that the foreign material causing chronic paronychia is derived from organisms of the nail fold, with C. albicans playing a prominent role [47]. C. albicans may contribute to lesion development by destroying the epidermal barrier rather than by supplying the foreign material [47].

Complications and Progression

Early diagnosis and prompt treatment are important to avoid complications such as chronic paronychia, osteomyelitis, nail deformity, felon, and septic tenosynovitis [27]. If paronychia is neglected, pus may spread under the nail sulcus to the opposite side, resulting in a "run-around abscess" [27]. Pus may also accumulate beneath the nail itself and lift the plate off the underlying matrix [27]. Advanced cases of paronychia may require more complex treatment, including removal of the nail to allow adequate drainage [27]. Hand infections are associated with a high rate of complications that are often difficult to manage [61]. Prompt diagnosis and early treatment are necessary to prevent complications such as hand stiffness, contractures, and amputation [51].

Classification

Acute Paronychia: Acute paronychia presents with clinical features similar to acute cellulitis at other anatomical sites [9]. The condition typically arises from a hangnail or trauma and is usually of streptococcal or staphylococcal origin [9]. It is rare for an acute lesion to progress to chronic paronychia [9].

Chronic Paronychia: Chronic paronychia is an inflammatory disorder of the nail folds characterized by chronic inflammation of the proximal nail fold, with or without nail plate abnormalities [10, 17]. The onset in adults is very gradual, often beginning with swelling and separation of the lateral nail fold from the side of the nail [9]. In children, the condition appears as marked rounding out and retraction of the posterior nail fold, from which thick pustular material can often be expressed [9]. Thumb-sucking is the most frequent predisposing factor in children [9]. The disease course is prolonged and interspersed with recurrent self-limited episodes of acute exacerbations [10].

Pathogenesis and Etiology: The initial step in the development of chronic paronychia is always mechanical or chemical trauma that produces cuticle damage [10]. When the cuticle is damaged or lost, the epidermal barrier of the proximal nail fold is destroyed, exposing the tissue to environmental hazards [10]. Irritants and allergens may then penetrate the proximal nail fold, producing an inflammatory reaction of the nail fold and nail matrix [10]. This inflammatory reaction interferes with normal nail growth and the formation of a new cuticle [10]. Chronic paronychia results from exposure to these irritants and allergens [17]. Debris from monilia stimulates chronic inflammation, which often aggravates the original defect [9].

Other Considerations: Chronic paronychia almost exclusively affects housewives and some occupational groups exposed to environmental factors that may damage the cuticle [10, 17]. The mechanisms of infection, trauma, and prolonged immersion of the hands in water are not sufficient to explain the chronic forms of paronychia [11]. Candida is just a colonizer of the proximal nail fold in most patients with chronic paronychia, and Candida eradication was not associated with clinical cure in most patients [8]. The clinical differential diagnosis of a new periungual or subungual lesion should include tumor metastasis to the nail unit, which should be considered in oncology patients and previously cancer-free individuals [16]. If the primary involvement is in the nail proper and not in the soft tissue about the nail, the terminology for paronychia will have to be changed [53].

Clinical Presentation

Acute Paronychia

Acute paronychia presents clinically similarly to acute cellulitis at other sites [9]. The history typically reveals pain that has progressively worsened over several days [15]. On physical examination, the eponychium appears tender, swollen, and erythematous [15]. A purulent collection may be present under the nailfold, but not under the nail plate itself [15]. Erythema does not extend proximal to the distal interphalangeal joint [15]. Radiographs are normal except for soft tissue swelling dorsally in the affected region [15].

Chronic Paronychia

Chronic paronychia is defined as inflammation of the tissue surrounding the nail plate [9]. In adults, onset is very gradual, often beginning with swelling and separation of the lateral nail fold from the side of the nail [9]. Some adults present with only one side of the posterior nail fold involved after the lesion has been present for several years [9]. In children, the lesion appears as marked rounding out and retraction of the posterior nail fold, from which thick pustular material can often be expressed [9].

Symptoms are present for more than 6 weeks at diagnosis [22]. The presentation includes erythema, swelling, and pain, though the degree of erythema and swelling is often less than that associated with acute paronychia [22]. Episodic exacerbation of symptoms may follow exposure to moist environments [22]. The proximal nail fold may become raised and separated from the underlying nail [22]. Associated nail changes include ridging, grooving, discoloration, and/or rounding of the nail plate [22].

The pathophysiology involves two basic components: a pocket that holds moisture and allows the survival of many different organisms, and an anatomic deformity of rounding out and retraction of the posterior nail fold due to foreign material in the dermis [9]. This dermal change assures the continuing presence of the pocket [9]. The debris stimulates chronic inflammation, which often aggravates the original defect [9]. The cuticle can be injured by manicuring, occupational trauma, frequent handwashing, continuous exposure to water, and/or irritative compounds [10]. When the cuticle is damaged or lost, the epidermal barrier of the proximal nail fold is destroyed, exposing it to environmental hazards [10]. Irritants and allergens may penetrate the proximal nail fold, producing an inflammatory reaction of the nail fold and nail matrix [10]. This reaction interferes with normal nail growth and the formation of a new cuticle [10].

Chronic paronychia is commonly seen in housewives and housemaids resulting from exposure to irritants and allergens [17]. The mechanisms of infection, trauma, and prolonged immersion of the hands in water are not sufficient to explain the chronic forms of the disease [11]. The underlying cause is generally agreed to be prolonged exposure to (cold) water, allowing Candida and Pseudomonas species to act as opportunist pathogens [19]. In a 1962 study, all patients had a positive culture for C. albicans from the nail fold before biopsy [46]. Cultures from the dermis of the paronychia were all negative, and there was no yeast growth on any of the bacterial cultures taken from these areas [46]. Fungal infections of the hand are most commonly cutaneous infections involving the skin and nails [7]. Candida and nondermatophyte infections often involve the surrounding nail folds, causing paronychia in addition to nail plate disease [23].

The combination of persistent, active inflammation, compromised vasculature, poor hand hygiene, poor healing, and a reluctance to seek treatment may allow paronychia to evolve and erode into the joint space [13]. Further diagnostic testing may be warranted in atypical cases in which malignancy or systemic etiologies are suspected [22]. The clinical differential diagnosis of a new periungual or subungual lesion should include tumor metastasis to the nail unit not only in oncology patients, but also in previously cancer-free individuals [16]. Physicians should consider squamous cell carcinoma of the nail unit in each case of a nail abnormality unresponsive to topical treatment [29].

Investigations

Clinical Diagnosis: Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [32]. The clinical differential diagnosis of a new periungual or subungual lesion should include tumor metastasis to the nail unit in oncology patients and previously cancer-free individuals [16].

Laboratory: Baseline bacterial cultures and nail clippings for fungus identification are utilized to assess antimicrobial effect and guide treatment [14]. Fungal infections of the hand can be treated with topical or local therapy [7].

Other Considerations: Early osteomyelitis of the bone can be detected long before the roentgenogram reveals evidences of destruction [58]. A randomized phase 2 trial evaluated the efficacy of twice daily 1% or 2% PVP-I topical solution versus vehicle-control in adult patients with cancer therapy-associated paronychia as evidenced by a two-grade reduction on the six-point Paronychia Severity Grading (PSG) scale [14]. Secondary objectives of the PVP-I trial assessed the impact on quality of life, the antimicrobial effect obtained from baseline bacterial cultures and nail clippings for fungus identification, and safety [14].

Treatment

Non-Operative

In the absence of pus under the nail or in the nailfold, the standard management for acute paronychia consists of oral anti-staphylococcal antibiotics, with or without warm saline soaks [15]. Proponents of warm soaks argue that heat encourages the spontaneous drainage of occult pus [15]. A 30-year literature review found no evidence supporting the superiority of either oral antibiotics or incision and drainage for acute paronychia [15]. For chronic paronychia, care of the nail folds is more important than the medication applied [31]. Chemical sealing of the proximal nail fold with cyanoacrylate glue heals and fills the gap between the nail fold and nail plate within 6–8 weeks [5]. Low-level laser therapy (LLLT) required an average of 20.4 ± 18.32 days of therapy to reach the treatment endpoint in chronic cases [12]. Fluconazole at 50 mg/day is both effective and safe for managing chronic paronychia [28]. Conversely, terbinafine shows no significant difference in efficacy compared to placebo for candidal nail disease after 12 weeks of therapy [49]. Early paronychia can be arrested and cured in a few days without nail removal by lifting the cuticle and inserting a sterile rubber ribbon [55]. A simple procedure should be attempted first in almost every case, as many patients may be cured without recourse to nail removal [6].

Operative

Indications: Surgery is indicated in the presence of an abscess [15]. Severe paronychia with run-around infection involving both nail folds may require specific operative techniques [24].

Surgical Approach / Technique: When an abscess is present, a skin incision is made on the eponychium or a portion of the nail plate is removed [15]. The Swiss roll technique is a simple method for treating chronic and severe acute paronychia with run-around infection involving both nail folds [24]. The square flap technique preserves nail plate length, a major advantage for maintaining nail appearance and function [25]. This technique cured paronychia in all but 2 cases, measured by cuticle regrowth [50]. Severe paronychia can also be treated by burning holes through the nail with a heated wire to drain pus [4]. A simple eponychial marsupialization procedure has been highly effective in curing chronic paronychia [48].

Adjuncts: The use of packing and postincision soaks varies [15]. In a randomized phase 2 trial, the primary objective was to evaluate the efficacy of twice daily 1% or 2% PVP-I topical solution versus vehicle-control in adult patients with cancer therapy-associated paronychia, defined by a two-grade reduction (or reduction to grade 0 if involved nails were grade 1) on the six-point Paronychia Severity Grading (PSG) scale [14]. Secondary objectives assessed the impact on quality of life, the antimicrobial effect of PVP-I obtained from baseline bacterial cultures and nail clippings for fungus identification, and safety [14].

Other Considerations: Immunosuppressed patients are at a much higher risk of developing a complicated infection [15].

Recovery

Non-Operative

Light activity (weeks): Following chemical sealing with cyanoacrylate glue, the gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks [5]. In a single case of severe paronychia treated by burning holes through the nail with a heated wire, the patient returned to full duty by the fifth morning [4].

Operative

No evidence is provided for operative recovery timelines.

Key Evidence

  • [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. [1] (10.1136/bmj.4.5730.257)
  • [L5] Chronic keratinaceous paronychia should be regarded as a potential complication of nail biting. [2] (10.1136/bmj.280.6208.189-g)
  • [L2] En bloc excision of the proximal nail fold is a useful method in recalcitrant chronic paronychia. [3] (10.1111/j.1524-4725.2006.32079.x)
  • [L5] The author reports a single case of severe paronychia treated by burning holes through the nail with a heated wire to drain pus, resulting in instant relief and the patient returning to full duty by the fifth morning. [4] (10.1136/bmj.2.4417.299-a)
  • [L4] The gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks, providing relief from chronic paronychia. [5] (10.25259/csdm_132_2023)
  • [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. [6] (10.1056/nejm193412062112313)
  • [L5] Fungal infections of the hand are most commonly cutaneous infections involving the skin and nails and can be treated with topical or local therapy. [7] (10.1016/j.hcl.2020.03.009)
  • [L1] Candida eradication was not associated with clinical cure in most patients, indicating that Candida is just a colonizer of the proximal nail fold. [8] (10.1067/mjd.2002.122191)
  • [L4] [9] (10.1177/000992286800700213)
  • [L5] [10] (10.5070/d32wb4g9wf)
  • [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. [11] (10.1159/000255443)
  • [L4] Chronic paronychia required on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint. [12] (10.5978/islsm.10.133)
  • [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. [13] (10.1111/j.1440-0960.2012.00967.x)
  • [L2] [14] (10.1007/s10637-019-00825-0)
  • [L5] [15] (10.1016/j.jhsa.2011.11.021)
  • [L4] The clinical differential diagnosis of a new periungual or subungual lesion (with or without an associated nail plate dystrophy) should include tumor metastasis to the nail unit not only in oncology patients, but also in previously cancer-free individuals. [16] (10.1097/00042728-200103000-00014)
  • [L4] Chronic paronychia is an inflammatory disorder of the nail folds, commonly seen in housewives and housemaids, resulting from exposure to irritants and allergens. [17] (10.4103/0019-5154.123482)
  • [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. [19] (10.1136/bmj.2.6200.1294-a)
  • [L4] Fifty-nine patients with proved monilial paronychia were treated with the nail polish sealer method. [20] (10.1001/archderm.1955.03730340045008)
  • [L5] [22] (10.5435/jaaos-22-03-165)
  • [L5] [23] (10.1016/j.jhsa.2013.11.017)
  • [L4] The Swiss roll technique is a simple method for the treatment of chronic and severe acute paronychia with run around infection involving both nail folds. [24] (10.1097/bth.0b013e3181ec089e)
  • [L5] Moreover, this technique preserves nail plate length, which is a major advantage in maintaining both nail appearance and function. [25] (10.5935/scd1984-8773.2026180505)
  • [L4] [27] (10.1097/01.bth.0000163575.00615.69)
  • [L4] These results show that 50 mg/day fluconazole is both effective and safe in the management of chronic paronychia. [28] (10.3109/09546639909056029)
  • [L4] Physicians should consider SCCNU in each case of a nail abnormality unresponsive to topical treatment. [29] (10.1016/j.jhsa.2018.01.010)
  • [L4] Although a small number of patients were treated, they all improved at the same rate; probably because the care of the nail folds is more important than the medication applied. [31] (10.1097/00043764-196606000-00039)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [32] (10.1016/j.hcl.2020.03.002)
  • [L4] [46] (10.1001/archderm.1962.01590090066015)
  • [L4] [47] (10.1001/archderm.1964.01590270141032)
  • [L4] [48] (10.1097/00006534-197607000-00011)
  • [L1] The results indicate that there is no significant difference in efficacy between terbinafine and placebo in candidal nail disease after 12 weeks of therapy. [49] (10.3109/09546639209088701)
  • [L4] The novel method cured paronychia in all but 2 cases, measured by cuticle regrowth. [50] (10.1016/j.jaad.2016.02.1154)
  • [L5] Prompt diagnosis and early treatment are necessary to prevent complications such as hand stiffness, contractures, and amputation. [51] (10.1016/j.jhsa.2014.03.031)
  • [L4] The paper suggests that if this organism is the etiologic agent, the terminology will have to be changed since the primary involvement is in the nail proper and not in the soft tissue about the nail. [53] (10.1001/archderm.1928.02380130077005)
  • [L5] Early paronychia can be arrested and cured in a few days without the necessity of nail removal through a conservative method of lifting the cuticle and inserting a sterile rubber ribbon. [55] (10.1056/nejm192511051931904)
  • [L4] Early osteomyelitis of the bone can be detected long before the roentgenogram reveals evidences of destruction. [58] (10.1097/00000658-194001000-00013)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [61] (10.1016/j.hcl.2020.03.010)
  • [L4] Most hand infections are the result of minor wounds that have been neglected. [62] (10.1016/j.ijid.2005.06.009)

See Also

References

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

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

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

[4] Treatment of Severe Paronychia. BMJ. 1945. DOI: 10.1136/bmj.2.4417.299-a

[5] 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

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

[7] Fungal Infections of the Hand. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.009

[8] 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

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

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

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

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

[13] 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

[14] 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

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

[16] Metastatic Tumors to the Nail Unit. Dermatologic Surgery. 2001. DOI: 10.1097/00042728-200103000-00014

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

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

[20] USE OF NAIL POLISH SEALER IN TREATMENT OF MONILIAL PARONYCHIA. Archives of Dermatology. 1955. DOI: 10.1001/archderm.1955.03730340045008

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

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

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

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

[27] DAREJD Simple Technique of Draining Acute Paronychia. Techniques in Hand & Upper Extremity Surgery. 2005. DOI: 10.1097/01.bth.0000163575.00615.69

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

[29] Squamous Cell Carcinoma of the Nail Unit: Review of the Literature. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.01.010

[31] The Treatment of Chronic Paronychia. Journal of Occupational and Environmental Medicine. 1966. DOI: 10.1097/00043764-196606000-00039

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

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

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

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

[49] Terbinafine in chronic paronychia and candida onychomycosis. Journal of Dermatological Treatment. 1992. DOI: 10.3109/09546639209088701

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

[51] Acute Hand Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.031

[53] CHRONIC PARONYCHIA. Archives of Dermatology. 1928. DOI: 10.1001/archderm.1928.02380130077005

[55] The Treatment of Early Paronychia. The Boston Medical and Surgical Journal. 1925. DOI: 10.1056/nejm192511051931904

[58] NEW INCISION FOR CLOSED SPACE INFECTION (FELON) INVOLVING DISTAL PHALANX OF FINGER. Annals of Surgery. 1940. DOI: 10.1097/00000658-194001000-00013

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

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

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Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

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.

Creative Commons may be contacted at creativecommons.org.