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Clinicians › Hand

Paronychia (Infection Beside the Nail)

24 citationsUpdated Aug 2026

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

Overview

Hand infections represent a diverse array of entities with significant potential for serious morbidity [6]. These conditions are frequently associated with high complication rates that are often difficult to manage [1]. Most hand infections result from neglected minor wounds [2]. Complications associated with specific etiologies, such as mycobacterial hand infections, can be particularly significant [7].

Fungal infections of the hand are most commonly cutaneous, involving the skin and nails, and can be treated with topical or local therapy [3]. Physicians should consider squamous cell carcinoma of the nail unit (SCCNU) in cases of nail abnormality unresponsive to topical treatment [4]. While acute paronychial abscesses are generally treated operatively, there is no consensus on the best surgical technique [14]. Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia [8].

Simple trephination in cases of subungual hematoma of any size with or without underlying fracture is associated with a low infection rate and good cosmetic outcome, with exceptions for fractures requiring surgical stabilization or entrapped nail matrix [9]. Nail bed reconstruction using single-layer bovine acellular dermal matrix offers advantages of no donor site morbidity and the ability to reconstruct multiple nail beds [12].

Anatomy & Pathophysiology

Hand and upper-extremity infections are primarily clinical diagnoses, though imaging and laboratory evaluation aid in confirmation [17]. Most cases result from minor wounds that have been neglected [2]. Prompt diagnosis and early treatment are necessary to prevent complications such as hand stiffness, contractures, and amputation [20]. With prompt and appropriate care, most soft tissue hand infection patients can achieve full resolution of their infections [15].

Chronic hand infections are uncommon and require a high index of suspicion for early diagnosis [10]. These are grouped by microorganism into bacterial (mycobacterial and others), fungal, and viral types [10]. Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms [13]. Non-tuberculous mycobacterial tenosynovitis of the hand and wrist are difficult to treat [26]. Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection [25].

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 [24]. HIV infection increased the risk of developing a hand infection but did not lead to an increased risk of revision surgery or ablation [27]. Many nail bed injuries are preventable, and targeted prevention strategies should be considered [28].

Classification

Fungal Infections: These are primarily cutaneous infections involving the skin and nails [3]. Management typically involves topical or local therapy [3].

Acute Paronychia: Acute paronychial abscesses are generally treated operatively [14].

Clinical Presentation

Hand and upper-extremity infections are primarily a clinical diagnosis [17]. Imaging and laboratory evaluation aid in the diagnosis of these conditions [17].

Most soft tissue hand infection patients can achieve full resolution of their infections with prompt and appropriate care [15].

Investigations

Laboratory: Early identification of atypical hand infections requires appropriate laboratory testing [13].

Treatment

Non-Operative

Fungal infections of the hand, which commonly involve the skin and nails, can be treated with topical or local therapy [3]. Current concepts for the treatment of common hand infections are reviewed to increase physician awareness of diagnosis and management [5].

Operative

Indications: 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 [13]. Treatment options for community-associated methicillin-resistant Staphylococcus aureus (MRSA) hand infections differ from those for routine hand infections, which must be considered during management [19].

Surgical Approach / Technique: Simple trephination for subungual hematoma of any size, with or without underlying fracture, is associated with a low infection rate and good cosmetic outcome, except in cases of fractures requiring surgical stabilization or entrapped nail matrix [9]. The eponychium flap performed to increase the size and improve the shape of the nail is a safe, reproducible procedure that generates good cosmetic and functional results with a low rate of complications [23].

Complications

Infection (PJI): Complications associated with mycobacterial hand infections can be significant [7]. Chronic hand infections require a high index of suspicion for early diagnosis [10].

Recovery

Light activity (weeks): The direct flow island flap is superior in terms of outcome for nail bed reconstruction, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone [11].

Full activity (months): The direct flow island flap is superior in terms of outcome for nail bed reconstruction, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone [11].

Complete recovery / outcome plateau (months): The direct flow island flap is superior in terms of outcome for nail bed reconstruction, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone [11].

Rehabilitation protocol: The direct flow island flap is superior in terms of outcome for nail bed reconstruction, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone [11].

Functional milestones: The direct flow island flap is superior in terms of outcome for nail bed reconstruction, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone [11].

Other Considerations: The direct flow island flap is superior in terms of outcome for nail bed reconstruction, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone [11].

Key Evidence

  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [1] (10.1016/j.hcl.2020.03.010)
  • [L4] Most hand infections are the result of minor wounds that have been neglected. [2] (10.1016/j.ijid.2005.06.009)
  • [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. [3] (10.1016/j.hcl.2020.03.009)
  • [L4] Physicians should consider SCCNU in each case of a nail abnormality unresponsive to topical treatment. [4] (10.1016/j.jhsa.2018.01.010)
  • [L5] This article reviews the clinical spectrum and microbiology of the most common infections of the hand and discusses current concepts for their treatment to increase physician awareness of diagnosis and management. [5] (10.1302/2058-5241.4.180082)
  • [L5] Hand infections include a diverse array of entities with potential for serious morbidity. [6] (10.1016/j.jhsa.2011.05.035)
  • [L4] The complications associated with mycobacterial hand infections can be significant. [7] (10.1177/1558944720940064)
  • [L5] Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia. [8] (10.5435/jaaos-22-03-165)
  • [L5] Based on the best available literature, simple trephination in cases of subungual hematoma of any size with or without underlying fracture appears to be associated with a low infection rate and good cosmetic outcome, with exceptions for fractures requiring surgical stabilization or entrapped nail matrix. [9] (10.1016/j.jhsa.2013.04.009)
  • [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. [10] (10.1016/j.jhsa.2014.04.003)
  • [L4] The direct flow island flap is superior in terms of outcome, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone. [11] (10.1177/15589447211064359)
  • [L4] The technique offers advantages of no donor site morbidity and the ability to reconstruct multiple nail beds. [12] (10.1016/j.jhsa.2016.10.010)
  • [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. [13] (10.1016/j.jhsa.2025.09.023)
  • [L5] While acute paronychial abscesses are generally treated operatively, there is no consensus on the best surgical technique. [14] (10.1016/j.jhsa.2011.11.021)
  • [L4] With prompt and appropriate care, most soft tissue hand infection patients can achieve full resolution of their infections. [15] (10.7717/peerj.513)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [17] (10.1016/j.hcl.2020.03.002)
  • [L4] This should be taken into account when managing seemingly routine hand infections given that the treatment options are different for MRSA infections. [19] (10.1016/j.jhsa.2007.01.006)
  • [L5] Prompt diagnosis and early treatment are necessary to prevent complications such as hand stiffness, contractures, and amputation. [20] (10.1016/j.jhsa.2014.03.031)
  • [L4] The eponychium flap performed to increase the size and improve the shape of the nail is a safe, reproducible procedure that generates good cosmetic and functional results, presenting a low rate of complications. [23] (10.1016/j.jhsg.2025.02.009)
  • [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. [24] (10.1016/j.hcl.2020.03.012)
  • [L5] Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. [25] (10.5435/jaaos-20-06-373)
  • [L3] NTM tenosynovitis of the hand and wrist are difficult to treat. [26] (10.1016/j.main.2014.12.004)
  • [L3] HIV infection increased the risk of developing a hand infection but did not lead to an increased risk of revision surgery or ablation. [27] (10.1177/1753193420977791)
  • [L4] Many of these injuries are preventable, and targeted prevention strategies should be considered. [28] (10.1177/1753193419826465)

See Also

References

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

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

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

[4] 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

[5] Infections of the hand: an overview. EFORT Open Reviews. 2019. DOI: 10.1302/2058-5241.4.180082

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

[7] Mycobacterial Infections of the Hand. HAND. 2020. DOI: 10.1177/1558944720940064

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

[9] Controversies in the Treatment of Nail Bed Injuries. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.04.009

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

[11] Does the Nail Bed Regenerate?. HAND. 2021. DOI: 10.1177/15589447211064359

[12] Nail Bed Reconstruction Using Single-Layer Bovine Acellular Dermal Matrix. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2016.10.010

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

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

[15] Hand infections: a retrospective analysis. PeerJ. 2014. DOI: 10.7717/peerj.513

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

[19] Community-Associated Methicillin-Resistant Staphylococcus aureus Hand Infections in an Urban Setting. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2007.01.006

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

[23] 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

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

[25] Flexor Tendon Sheath Infections of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-373

[26] Non-tuberculous mycobacterial infections of the hand. Chirurgie de la Main. 2015. DOI: 10.1016/j.main.2014.12.004

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

[28] 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

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