DERMATOLOGIC

SURGERY

Chronic paronychia treatment:

Square flap technique
Luiza Ferreira Vieira dAlmeida, MD,a Francine Papaiordanou, MD,a Erika Ara

ujo Machado, MD,a
a
b
Guillermo Loda, MD, Robert Baran, MD, and Robertha Nakamura, MDa
Rio de Janeiro, Brazil, and Cannes, France
Background: Chronic paronychia is an inflammatory process of the periungual folds that lasts longer than
6 weeks. It manifests as hypertrophy of the proximal and lateral nailfolds, absence of cuticle, progressive
retraction of the proximal nailfold, and onychodystrophy. Surgical treatment is recommended if there has
been insufficient response to 6 months of appropriate medical therapies.
Objective: We describe a new surgical technique that removes the fibrotic tissue without complete excision
of the proximal and lateral nailfold, minimizing nailfold retraction and recovery time.
Methods: We present a case series of 34 fingers (9 patients) treated with this new technique.
Results: All nailfolds healed well without complications. At the end of the follow-up, all fingers, apart from
2, were relieved of the preoperative symptoms. The length of the ungual plate was maintained in all
patients, with no retraction of the nailfolds.
Limitations: Follow-up period of 6 months and small sample size are limitations of this study.
Conclusion: This surgical technique can provide an alternative treatment for chronic paronychia, with good
prognosis during follow up-period and optimal cosmetic results. ( J Am Acad Dermatol 2016;75:398-403.)
Key words: inflammation; nail; nail surgery; nailfold; paronychia; surgery.

hronic paronychia is characterized by an

inflammatory process of the periungual
folds that lasts longer than 6 weeks.1
Clinically, it exhibits hypertrophy of the proximal
or lateral nailfolds, absence of cuticle, progressive
retraction of the proximal nailfold, and variable
onychodystrophy, related to spreading inflammation
to the proximal matrix. Primarily, it is more common
in those who are exposed to nail cuticle trauma and
frequent immersion in watereincluding cooks, dishwashers, and housecleanerseand represents 18% of
all ungual dystrophies.2
A combination of factors is responsible for the
beginning and perpetuation of chronic paronychia.
At first, the periungual region becomes uncovered as
a result of cuticle disruption caused by irritant

contact dermatitis or trauma; the most common

trauma in Brazil is cuticle trimming during a manicure.3 The loss of this effective seal favors persistent
retention of moisture, thus increasing local humidity
and infection caused by bacteria or, more often,
fungi, especially yeasts (Candida albicans).4,5
Repeated bouts of inflammation and infection leads
to nailfold fibrosis and retraction that further exposes
nail grooves.6 This cycle of continued nailfold injury
impairs the ability to regenerate a cuticle and leads to
persistent paronychia (Fig 1).
Medical treatment includes exclusion of causal
factors, in particular primary irritant agents and
infections, along with decreasing inflammation and
fibrosisewith antifungal and antibacterial therapies,
topical corticosteroids, and topical tacrolimus.5-8

From the Dermatology Institute Prof. Rubem David Azulay, Nail

Studies Center, Rio de Janeiro,a and Universit
e de Franche-Compt
e,
Nail Disease Center, Cannes.b
Funding sources: None.
Conflicts of interest: None declared.
Accepted for publication February 2, 2016.
Reprint requests: Luiza Ferreira Vieira dAlmeida, MD, Dermatology
Institute Prof. Rubem David Azulay, Nail Studies Center, Rua

Augusto Camossa Saldanha, 260 e Barra da Tijuca, Rio de

Janeiro/RJ e Brazil, CEP 22793-310. E-mail: luizadalmeida@
gmail.com.
Published online March 4, 2016.
0190-9622/$36.00
2016 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2016.02.1154

398

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because of green nail syndrome. Surgery was proSurgical treatment is only recommended if there has
posed in the absence of improvement after 6 months
been insufficient response to 6 months of approof medical treatment with the regimen previously
priate medical therapies.5,6,9
described.
We describe a series of 34 nailfolds treated with a
The square flap technique was designed and first
new surgical technique that removes periungual
performed by the senior author. The procedure
fibrosis while preserving the epidermis. This method
begins with a digital block performed with 2 mL
allows for healing of paronychia to occur without
of lidocaine 2% without
nailfold contraction, thus
epinephrine (1 mL for each
maintaining nail plate length
CAPSULE SUMMARY
side), followed by an appli(Fig 2). The aesthetic result is
cation of a tourniquet that
prompt. The nail plate dysSurgical treatment for chronic
stays in place throughout
trophy gradually improves
paronychia is recommended when the
the procedure to prevent
and
the
cuticles
are
associated fibrosis does not improve
excessive bleeding. The surcompletely regrown within,
after medical management.
gery lasts for about 30 mion average, 6 weeks postThis article proposes a new surgical
nutes; however, if it lasts
procedure (range 4-6 weeks),
approach that removes fibrotic tissue
longer than that, the authors
reducing the healing time.
and minimizes nailfold retraction.
recommend removing the
The surgery was proposed
tourniquet briefly to allow
for patients with recalcitrant
This procedure has a high cure rate and
reperfusion. Oral cephalexin
paronychia who were bothan excellent cosmetic outcome.
(500 mg) 4 times daily was
ered by the nail appearance
prescribed for 10 days, startand pain caused by the acute
ing 2 days before the surgical procedure.
flareups, after 6 months of medical management
The surgical technique (Fig 3 and Video [at
with no improvement of the fibrosis.
http://www.jaad.org]) starts with 4- to 5-mm oblique
marking guidelines on the proximal nailfold, upon
METHODS
which the first incisions are made. The next step is an
This is a prospective case series of 34 cases (34
incision, parallel to the epidermis, at the distal
nailfolds from 9 patients) of chronic paronychia,
thickened proximal nailfold. This incision is made
treated with the new surgical technique between July
underneath the fibrotic tissue, above the nail, using it
and December 2010. The follow-up period was
as a guide to carefully avoid ungual matrix damage.
6 months. All patients provided consent. The study

tica em Pesquisa,
If done correctly, there should be fibrosis above
was approved by the Comit^
e de E
incision and nail matrix below it.
which is the Brazilian committee responsible to
As a result, we have a square flap filled with
approve, monitor, and review all research involving
fibrosis. The flap is tilted backward to allow visualhuman beings.
ization of the fibrotic tissue and its removal with the
The 9 patients were recruited from the Nail Studies
scalpel blade. If the lateral folds are involved, it is
Center and presented with chronic paronychia for at
possible to cut off the fibrotic material with a scalpel,
least 3 years. All patients had persistent induration
tilting the blade at a 45-degree angle. The primary
and fibrosis of proximal or lateral nailfolds, nail
closure is made with a simple interrupted suture.
surface irregularity, and no active pus discharge. A
Through this procedure, we are able to preserve the
detailed history was taken. Any subject with comorepidermis of the proximal and lateral nailfold, minus
bidities or concomitant dermatoses that could be
the fibrosis.
responsible for paronychia or those with coexistent
All patients were seen 24 hours after the proceonychomycosis were excluded from the study.
dure and every week during the first month for
All patients had been previously treated and failed
dressing changes. The postoperative care involved
a 6-month regimen protocol, that being: (1) oral
daily washing with chlorhexidine soap and daily
fluconazole 150 mg once a week for 6 months; and
occlusive dressing with topical dexpanthenol oint(2) topical therapyeclobetasol propionate ointment
ment until complete healing. Topical dexpanthenol
during the first 15 days; occlusive form, to increase its
not only accelerates re-epithelization in wound
anti-inflammatory effect and efficacy in treating
healing but it acts like a moisturizer, improving
fibrosis; followed by ketoconazole ointment daily
stratum corneum hydration and reducing transepiand betamethasone dipropionate ointment once a
dermal water loss.10,11
week for 6 months. In addition to the protocol, 4
Postoperative evaluations occurred at weeks 6,
patients (19 nailfolds, 55% of nailfolds) were treated
12, and 24 after procedure with clinical assessment
with topical gentamicin ointment for 15 days
d

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AUGUST 2016

Fig 1. Pathogenesis of chronic paronychia (modified from Relhan et al6).

Fig 2. Nail plate length before (A) and after (B) the square
flap technique.

and photographic record of each finger. The

following parameters were evaluated in all visits:
nail plate dystrophy (present or absent), infection
(present or absent), pain (absent, mild, moderate, or
severe) and length of the nail plate (measured by
comparison with the contralateral finger). The
aesthetic result was measured comparing to the
contralateral digit. The patient was deemed cured
when the cuticle was fully regrown.

RESULTS
The 9 patients were female with an average
age of 56 years (range 39-75 years). Only hand

nails were involved in our patients with the

commonest being the index finger of the dominant hand.
The total number of nailfolds treated was 34, of
which 32 were completely cured by the end of the
follow-up. The median time for cuticle regrowth
(cure) was 6 weeks, varying from 4 weeks (12 nails)
to 6 weeks (20 nails). The sutures were removed on
postoperative day 14. All patients were satisfied with
the results.
The main postsurgical symptom was painebefore
pain treatment, pain was rated severe by 8 patients
and moderate by 1 patient. After pain management
medication, pain was rated mild by 7 patients and
absent by 2 patients. It was successfully managed
with ketoprofen (100 mg twice daily) and dipyrone
(a nonopioid analgesic) (1 g 3 times a day). The
patients were allowed to take the medication as soon
as 1 hour after the procedure and no associated
bleeding was seen. Pain management therapy lasted
for 14 days.
All nailfolds healed well by the first postoperative
consult (week 6) without any wound complication
such as infection, wound dehiscence, suture margin
necrosis, or hemorrhage. Furthermore, 32 nails were
considered aesthetically consistent with the contralateral. The length of the ungual plate was maintained in 32 nails, with no retraction of the proximal
nailfold, measured by comparison to the contralateral digit.
At the end of follow-up, all patients were relieved
of the preoperative symptoms and there was no

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Ferreira Vieira dAlmeida et al 401

Fig 3. Square flap technique for surgical treatment of chronic paronychia. A, Oblique marking
guidelines on proximal nailfold. B, Incision using guidelines. C, Incision parallel to the
epidermis, underneath fibrosis, carefully done to prevent damage to the nail matrix. D, Square
flap tilted backward. E, Fibrosis removal, saving the epidermis of proximal nailfold. F, Incision
on the lateral nailfold to remove lateral fibrosis. G, Fibrosis removal, saving the epidermis. H,
Proximal and lateral nailfolds showing absence of fibrotic tissue and intact epidermis. I,
Surgical closure with simple interrupted suture.

evidence of nail or fingertip deformity. All the

operated fingers were functionally normal. No patients reported chronic pain. The replacement of a
dystrophic nail plate for a healthy nail plate was
observed in a range of 12 to 24 weeks, median
24 weeks (Fig 4).

DISCUSSION
Chronic paronychia is a nail disorder commonly
seen in women age 30 to 60 years old, as was seen in
our series.12 Involvement of fingernails, especially
the index finger, is most common.9 It is an inflammatory reaction of the proximal or lateral nailfold
caused by a combination of factors.6 The appropriate
treatment involves exclusion of causal factors, in
particular primary irritant agents and infections; the
eradication of secondary infection and control of the

dermatitis; and decrease of the inflammation and

fibrosis.13
Cotton gloves covered by rubber gloves can be
used to avoid irritating agents. Topical or systemic
antifungals and antibacterial therapies are suggested
in cases where infection is suspected. Topical
corticosteroids, occlusive or intralesional, and tacrolimus are indicated when there is inflammation and
fibrosis.5,7,8,13 The medical therapy usually works
within the first month for 46% to 93% of patients,
depending on the treatment; higher response rates
are associated with topical corticosteroid use.5,8
All patients in this study were treated for at least
6 months with medical regimens and irritant avoidance regimen, which significantly improved infection and inflammation, but fibrosis persisted. When
all conservative measures fail leading to persistent

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Fig 4. Assessment of surgical intervention of chronic paronychia. A, Preoperative. B,

Postoperative week 6. C, Six months postoperative. Presence of cuticles and the resolution
of proximal nailfold hypertrophy in 3 fingers.

manifestations, surgical intervention is recommended.5,7 Furthermore, it is advised when there is no

improvement in local fibrosis after topical or intralesional treatment.7
Various surgical approaches have been devised
for this condition. In 1976, Keyser and Eaton14
described the removal of the dorsal surface of the
proximal nailfold maintaining its ventral portion,
without removing the ungual plate. In 1991, Bednar
and Lane15 compared eponychial marsupialization
with and without removal of the nail plate, and
concluded if onychodystrophy is present, nail avulsion should be part of the technique. In 1981, Baran
and Bureau16 described a technique excising en bloc
the proximal nailfold. In 2006, Grover et al9 modified
the en bloc technique, adding ungual plate removal.
These techniques cure chronic paronychia and are
easy to perform. However, their disadvantages are a
prolonged healing time, and retraction of the proximal nailfold that manifests a postoperative increase
of the nail plates length.
The Swiss roll technique is the most recent
described surgical modality for the treatment of
paronychia complicated with abscess.17 Lateral incisions of the proximal nailfold allow its elevation
and the drainage of the purulent collection. The
proximal nailfold is reflected proximally over a nonadherent dressing that is rolled up like a Swiss roll and
fixed to the skin with 2 anchoring nonabsorbable
sutures. After 48 hours the patient is reviewed; if the
wound is clean the anchoring sutures are removed,
and the proximal nailfold falls back to its original
position and heals by second intent. Although this
technique improves the acute process, it does not
solve the chronic fibrosis problem.
The square flap technique was developed as a
means to treat the chronic fibrosis caused by
paronychia. As a result of doing so, the persistent
cycle of cuticle damage, inflammation, fibrosis, and
repeated cuticle damage is interrupted, enabling the
re-establishment of the physiological architecture of

the nailfolds that in turn leads to healing of the

chronic paronychia itself.
This novel method cured paronychia in all but 2
cases, measured by cuticle regrowth. After analyzing
the photographs and the results, this situation may
have happened because lack of skin quality of the
nailfolds. The skin, hyperpigmented and atrophic,
could be compromised by insufficient vascular supply that has been damaged by the fibrosis.5,9 Having
that in mind, the nailfold skin quality is vital to
surgical success and, if it is impaired, this technique
may not be the best option. Another disadvantage is
that the technique is neither fast nor easy to perform,
requiring a skilled nail surgeon.
In turn, complete healing happens in 2 weeks and
cuticle regrowth occurs 6 weeks after surgery allowing the patient to return quickly to everyday activities. Furthermore, there is virtually no proximal
nailfold retraction leading to a superior cosmetic
outcome.
The square flap technique is a useful tool for the
surgical treatment of recalcitrant paronychia with
proximal and/or lateral nailfold fibrosis, nevertheless
good skin quality of the nailfolds is crucial for
optimal results. Larger scale randomized controlled
trials are needed to compare this novel surgical
technique to more well-established surgical and
medical treatments.
We thank Brian Simmons for his assistance in providing
language help and proofreading the first draft of article.
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