Dermatology Online Journal

Controversy: the role of yeasts in chronic paronychia: pro
Bianca Maria Piraccini
Abstracts of the Fifth Meeting of the European Nail Society:DOJ 9(1): 17G

Department of Dermatology – University of Bologna, Italy

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Chronic paronychia (CP) is a common nail disorder that almost exclusively affects adult women. It is clinically characterized by a chronic inflammation of the proximal nail fold with or without nail plate abnormalities. CP usually has a prolonged course interspersed with recurrent self-limited episodes of acute exacerbations.

Although the pathogenesis of CP is still being discussed, accumulating evidence indicates that in most cases the condition represents a clinical variety of contact urticaria1-2.

CP is most commonly an environmental disease that results from an impairment of the epidermal barrier of the proximal nail fold. The first step in the development of CP is always a mechanical or chemical trauma that produces cuticle damage. The cuticle can be injured in several ways including manicuring, occupational trauma, frequent handwashing, continuous exposure to water and/or irritative compounds. In fact CP almost exclusively affects housewives and some occupational groups which are exposed to environmental factors that may damage the cuticle. When the cuticle is damaged or lost, the epidermal barrier of the proximal nail fold is destroyed and the proximal nail fold is suddenly exposed to a variety of environmental hazards. Irritants and allergens may easily penetrate the proximal nail fold and produce an inflammatory reaction of the nail fold and nail matrix, which interferes with the normal nail growth and therefore with the formation of a new cuticle. The proximal nail fold becomes progressively separated from the nail plate by a pocket, which has an important role in maintaining and aggravating CP. In fact it becomes a receptacle for microorganisms and environmental factors that further promote the chronic inflammation. Candida sp. and bacteria can frequently be isolated from the proximal nail fold of patients with CP.

CP is therefore a multifactorial condition ,which can be induced and maintained by several causes. Depending on the major etiological factor, CP can be classified in the following types:

Contact allergy

CP may occasionally be a consequence of contact sensitization to common allergens. In these patients CP is due to an acute contact dermatitis of the proximal nail fold (allergic chronic paronychia) and the cause of sensitization may be disclosed by patch testing.

In our experience, allergic CP is most commonly caused by topical drug ingredients, rubber compounds and mineral oil additives.

Food hypersensitivity

CP due to immediate hypersensitivity reaction to foods is a variety of immediate contact dermatitis due to foods. It is more commonly seen in occupational food handlers but it can also occur in housewives with intense cooking activity. These patients develop an inflammatory reaction of the proximal nail fold associated with itching immediately after handling raw food ingredients. In our experience CP due to immediate food hypersensitivity is most commonly caused by tomatoes, garlic, onions and flour, but other vegetables and fish can occasionally be involved. The specific foods that are responsible for food hypersensitivity CP may, however, considerably vary in different countries, depending on the eating habits of the resident population. Conventional patch tests are not useful for the diagnosis of this type of CP, which can be clearly identified with a provocative test using fresh foods on the proximal nail fold.

Candida hypersensitivity

Patients with CP may develop a hypersensitivity to Candida antigens. A similar reaction has previously been reported in patients with chronic recurrent vaginitis6.

These patients have negative patch tests, negative provocative tests, harbor Candida sp. in their proximal nail fold but do not improve with systemic antifungals. They usually have an immediate reaction to the intradermal skin test with Candida and a positive provocative test to crude Candida antigen.

Irritative reaction

Most patients with CP have negative patch tests, negative provocative tests and negative cultures. These patients, who improve with preventive measures and topical steroids, have an irritative dermatitis of the proximal nail fold.

Candida paronychia

This is in our experience very uncommon, except for patients with chronic mucocutaneous candidiasis and HIV infection. In Candida paronychia, proximal nail fold inflammation is usually associated with proximal onycholysis or onychomycosis due to Candida. Candida hyphae can be isolated both from the proximal nail fold and clippings of the affected nail plate. Since the isolation of Candida sp. from the proximal nail fold is not exclusive to Candida paronychia3,8, most cases of CP due to other causes being frequently associated with secondary Candida colonization, the diagnosis of Candida paronychia can only be established on the basis of the results of treatment with systemic antifungals.

References

Zaias, N., Paronychia, in The nail in health and disease, 2nd ed., Zaias, N., Eds., Appleton & Lange, Norwalk, 1990, Chap 13.

Tosti, A., Guerra, L., Morelli, R., Bardazzi F., Fanti, P. A., Role of food in the pathogenesis of chronic paronychia, J Am Acad Dermatol, 27, 706, 1992.

Tosti A, Piraccini BM. Paronychia. In: Amin S, Lahti A, Maibach H I (eds). Contact urticaria syndrome . CRC Press Boca Raton. 1997; 267-278.

Hjorth, N., Roed-Petersen, J., Occupational protein contact dermatitis in food handlers, Contact Dermatitis, 2, 28, 1976.

Maibach, H., Immediate hypersensitivity in hand dermatitis, Arch Dermatol, 112, 1289, 1976.

Regulez, P., Garcia Fernandez, J. F., Moragues, M. D., Schneider, J., Quindos, G., Ponton, J., Detection of anti-Candida albicans IgE antibodies in vaginal washes from patients with acute vulvovaginal candidiasis, Gynecol Obstet Invest, 37, 110, 1994.

Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002;47:73-6.

Daniel III C R, Daniel M P, Daniel C M, Sullivan S, Ellis G. Chronic paronychia and onycholysis: a thirteen-year experience. Cutis 1996; 58: 397-401.

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