Nail frenulitis is an inflammatory reaction involving the skin folds around the nail that presents as acute or chronic purulent, tenderness and painful swelling of the perinail tissue, caused by an abscess in the nail fold. When the infection becomes chronic, transverse ridges appear at the base of the nail and new ridges appear with recurrence. The fingers are more commonly involved than the toes. The main susceptibility factors are injury resulting in separation of the nail epithelium from the nail plate and secondary invasion of septic cocci or yeasts into the moist nail grooves and nail folds. The common pathogenic bacteria are Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas, Aspergillus, or anaerobic bacteria; the most common pathogenic yeast is Candida albicans.
Clinical manifestations
1, Acute nail fungus: often occurs after injury or minor trauma, characterized by septic infection with pain, acute abscess formation (Staphylococcus) or erythema and swelling (Streptococcus).
2. Chronic nail folds: often caused by repeated minor trauma and exposure to water, irritants and allergic substances resulting in dermatitis followed by yeast colonization and secondary bacterial infection. Clinical features are inflammation of the proximal nail crease, manifested by painful erythema, edema, absence of nail microdermis, and nail bed injury resulting in abnormal nail plate surface. The course is chronic, overlapping with repeated self-limiting acute exacerbations. Tumors can sometimes present with a presentation similar to chronic nail infection, such as Bowen’s disease, keratoacanthoma, squamous cell carcinoma, endophytic chondromas, and anaplastic melanoma. Nail sulcus and pseudopurulent granuloma may occur with certain medications, such as systemic application of retinoids, anti-retrovirals, anti-epidermal growth factor antibodies, and epidermal growth factor tyrosine kinase inhibitors. It can also be caused by some rare causes such as ingrown nails and cutaneous leishmaniasis.
Laboratory tests are performed by swabbing secretions for bacteriological and fungal examinations, and patch tests if necessary.
Disease treatment
1. Systemic treatment: Acute nail infection should be treated effectively as soon as possible to prevent nail bed damage. Choose broad-spectrum antibacterial drugs that cover aerobic and anaerobic bacteria, such as amoxicillin/clavulanic acid, and if symptoms do not improve in 48 hours, surgical treatment should be taken. Chronic onychomycosis is treated with antifungal drugs (azoles are preferred) or antibacterial drugs as needed, and treatment needs to continue until the inflammation subsides and the nail tubercle is rebuilt and adheres to the nail plate, often for more than 3 months. In patients with recurrent acute exacerbations, treatment with intra-dermal or systemic glucocorticoids in combination with systemic antimicrobials may be instituted for 1 week. Chronic onychomycosis caused by cetuximab can be given with oral doxycycline, 100 mg each time, twice daily.
2, surgical treatment: acute nail infection when the infection is superficial and limited, can be incised and drained. If the infection is deep, under local anesthesia, lift the proximal 1/3 of the nail plate and place drainage strips under the proximal nail crease to drain the secretions. Chronic nail infections secondary to ingrown nails can be treated by removing the nail plate.
Topical treatment: topical azole antifungal drugs or topical clarithromycin solution, combined with anti-inflammatory treatment, such as topical medium-acting or strong glucocorticoid creams. For those who fail in conventional treatment, surgical treatment or low-dose superficial radiation therapy can be adopted. Drug-induced pseudopurulent granulomatous onychomycosis may be treated with daily topical 2% mupirocin/ clobetasol propionate ointment.
Disease prevention Chronic nail infections should be avoided by avoiding contact with water, irritants, allergens and trauma. Wear cotton gloves when in contact with water and rubber or plastic gloves on the outside, keep your hands dry, do not push the nail folds and do not use nail polish.
Causes
Nail fungus is caused by the incorrect direction of nail growth, causing inflammation, redness, swelling, pain, pus and other symptoms in the tissue next to the toe nail, inflammation over time, the tissue produces granulomas, making the toe nail sink deeper and deeper, not easy to heal themselves. The pathogenesis of the disease is from the wound invasion, along the nail groove spread, then the subcutaneous tissue congestion, edema, leukocyte tendency, followed by the degeneration of damaged tissue cells, necrosis, liquefaction; the formation of semi-ring abscess, pus can also be from the nail groove – side spread to the nail root of the subcutaneous and the opposite side of the nail groove.
Examination
Generally there is no special examination method, but the diagnosis can be made according to the symptoms manifested by nail fungus, examination. Leukocyte count and classification count: In unilateral onychomycosis, there is generally no significant change in white blood cells. After the formation of a sub nail abscess, when systemic toxicity symptoms occur due to the absorption of bacterial toxins, the white blood cell count and neutrophils increase significantly. Bacteriological and fungal examinations are performed by swabbing the secretions, and patch tests are performed if necessary.
Diagnosis
At the beginning, the subcutaneous tissue on one side of the nail becomes red, swollen and painful, some of them can subside by themselves, but some of them become pus rapidly, and the pus spreads from one side of the nail groove to the subcutaneous part of the nail root and the opposite side of the nail groove, forming a semi-annular abscess. If not treated in time, it can become chronic nail sulcus or chronic osteomyelitis. In chronic nail sulcus, there is a small pus sinus orifice next to the nail sulcus with granulation tissue protruding outward, and chronic nail sulcus can sometimes be secondary to fungal infection.
Complications
Proper handling of finger barbs, correct nail trimming, prevention of ingrown nails; attention to labor protection, fingers have a small wound, can be coated with 2.5% tincture of iodine, iodine volts, etc., to prevent infection.
1, usually take care of the skin around the nail, do not make any damage to it, nails should not be cut too short, not to pull the “barbs” by hand.
2, prevention is better than cure. Wooden thorns, bamboo thorns, sewing needles, fish bone thorns, etc. are the easiest foreign objects to pierce the nail groove in daily life, and should be extra careful when participating in labor or busy with household chores.
3, usually pay attention to finger care, after washing hands, before going to bed rub some Vaseline or skin cream, can enhance the skin around the nail groove resistance to disease.
4, the finger has a small injury, can be rubbed with 2% iodine, band-aid bandage to prevent infection.
5, if the pus has been septic should go to the hospital in time to cut, the pus drainage out. Prevent the infection from spreading and causing osteomyelitis of the finger bone.
6.If pus accumulates under the nail, the nail should be removed to facilitate adequate drainage and complete healing.