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Paronychia (Infection Beside the Nail)

44 citationsUpdated Aug 2026

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Overview

Paronychia is an infection of the nail fold that may involve bacterial or fungal pathogens. Staphylococcus pyogenes and Candida albicans are frequently cultured from infected nail folds in chronic paronychia [1]. However, Candida eradication was not associated with clinical cure in most patients with chronic paronychia, indicating that Candida is just a colonizer of the proximal nail fold [8]. Chronic keratinaceous paronychia should be regarded as a potential complication of nail biting [2]. 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].

Simple procedures should be tried first in almost every case of paronychia, as many patients may be cured without recourse to nail removal [6]. Severe paronychia can be treated by burning holes through the nail with a heated wire to drain pus, resulting in instant relief and return to full duty by the fifth morning [4]. Chemical sealing of the proximal nail fold with cyanoacrylate glue allows the gap between the proximal nail fold and nail plate to heal and fill up within 6–8 weeks, providing relief from chronic paronychia [5]. Fifty-nine patients with proved monilial paronychia were treated with the nail polish sealer method [17].

Chronic paronychia required on average 20.4 ± 18.32 days of low-level laser therapy (LLLT) to reach the treatment endpoint [10]. En bloc excision of the proximal nail fold is a useful method for treating recalcitrant chronic paronychia [3]. In a small study of chronic paronychia treatment, all patients improved at the same rate, suggesting that care of the nail folds is more important than the medication applied [25].

Anatomy & Pathophysiology

Hand and upper-extremity infections are primarily clinical diagnoses [26], though imaging and laboratory evaluation aid in diagnosis [26]. These infections encompass a diverse array of entities with potential for serious morbidity [27]. Most result from neglected minor wounds [48] and are associated with a high rate of complications that are often difficult to manage [47]. Prompt diagnosis and early treatment are necessary to prevent complications such as hand stiffness, contractures, and amputation [35].

Physicians must consider 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 [46].

The review discusses the surface, gross, and microscopic anatomy of the distal digit to facilitate surgical procedures in the nail unit with minimal residual impact [45]. Proper direction of incisions helps ensure proper direction of healing, which determines whether scarring of the nail bed/matrix occurs [49]. The distal phalanx has a dual blood supply [51].

Classification

Chronic Paronychia: Chronic paronychia is an inflammatory disorder of the nail folds [15]. Chronic keratinaceous paronychia is a potential complication of nail biting [2]. In children, chronic paronychia is predominantly associated with thumb-sucking, which causes maceration and creates a pocket for organisms like Candida albicans [13]. In adults, it is commonly seen in housewives and housemaids, resulting from exposure to irritants and allergens [15]. The mechanisms of infection, trauma, and prolonged immersion of the hands in water are not sufficient to explain the chronic forms of paronychia [9]. Candida is a colonizer of the proximal nail fold, as Candida eradication was not associated with clinical cure in most patients [8]. Candida paronychia is very uncommon except for patients with chronic mucocutaneous candidiasis and HIV infection [20].

Onychomycosis: Onychomycosis is the most common single cause of nail dystrophy [32]. It has a marked impact on quality of life, with patients reporting both functional and psychosocial impairment associated with their disease [32]. Affected nails in onychomycosis can disrupt the integrity of surrounding skin and increase the risk of secondary bacterial infection [32]. 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 [19]. Classification of onychomycosis includes superficial white, proximal subungual, distal subungual, and total dystrophic types [19]. Classification is determined from an examination of the nail [19]. Classifying onychomycosis offers clues to a causative organism and can guide treatment strategy and determine prognosis [19].

Superficial White Onychomycosis: Superficial white onychomycosis involves the nail plate and is a direct infection of the surface of the nail [19]. It presents as a chalky white appearance or white, powder-like scale on the surface of the nail plate that can be scraped off with a scalpel or microscope slide [19]. Superficial white onychomycosis is the most common presentation in the pediatric population [19]. Common infecting organisms include T. mentagrophytes and the nondermatophytes Aspergillus and Fusarium [19]. Superficial white onychomycosis can be treated with topical antifungals [19].

Proximal Subungual Onychomycosis: Proximal subungual onychomycosis is characterized by white discoloration at the proximal nail fold [32]. In this subtype, the white areas are within the nail plate [19]. The diagnosis can be confirmed by potassium hydroxide or cultures of parings off the plate [19]. Proximal subungual onychomycosis implies increased susceptibility to dermatophyte infection because of immunosuppression or greater susceptibility to chronic dermatophyte infection [19]. Proximal subungual onychomycosis is treated with systemic antifungals [19].

Distal Subungual Onychomycosis: Distal subungual onychomycosis is characterized by a thickened nail with white-yellow discoloration, subungual debris, and onycholysis [32].

Total Dystrophic Onychomycosis: Total dystrophic onychomycosis represents the most severe involvement of the nail, which can become thickened, dystrophic, and discolored in all subtypes [19].

Other Considerations: If the nail is white, one should consider superficial white or proximal subungual onychomycosis [19]. 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 [14].

Clinical Presentation

Paronychia is a common inflammatory condition of the nail fold often associated with infection, encompassing fungal, viral, or bacterial etiologies [31]. Chronic paronychia is defined by symptoms present for more than 6 weeks at the time of diagnosis [18]. Patients typically report erythema, swelling, and pain, though the degree of erythema and swelling is often less severe than that seen in acute paronychia [18]. Symptoms may undergo episodic exacerbation, frequently following exposure to moist environments [18].

Inspection reveals that the proximal nail fold in chronic cases may become raised and separated from the underlying nail [18]. Associated nail changes can include ridging, grooving, discoloration, and/or rounding of the nail plate [18]. The underlying cause is generally attributed to prolonged exposure to cold water, which allows Candida and Pseudomonas species to act as opportunist pathogens [16]. However, Candida eradication was not associated with clinical cure in most patients, indicating that Candida acts primarily as a colonizer of the proximal nail fold [8]. This is supported by findings where all patients had positive C. albicans cultures from the nail fold before biopsy, while Littman’s cultures from the dermis were negative [30].

In children, chronic paronychia is predominantly associated with thumb-sucking [13]. This habit causes maceration and creates a pocket for organisms like Candida albicans [13]. Neonatal paronychia represents a rare presentation of acute bacterial paronychia caused by clindamycin-resistant Staphylococcus aureus [31].

Atypical chronic sterile paronychia can lead to tissue and joint space destruction in patients with thromboangiitis obliterans [11]. 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 [11].

The clinical differential diagnosis of a new periungual or subungual lesion with or without associated nail plate dystrophy should include tumor metastasis to the nail unit [14]. Physicians should consider squamous cell carcinoma of the nail unit in each case of a nail abnormality unresponsive to topical treatment [23].

Investigations

Laboratory: Chronic paronychia is frequently associated with cultures positive for Staphylococcus pyogenes and Candida albicans [1]. Fungal infections of the hand can be treated with topical or local therapy [7]. In oncology patients and previously cancer-free individuals, the clinical differential diagnosis of a new periungual or subungual lesion with or without associated nail plate dystrophy should include tumor metastasis to the nail unit [14]. Physicians should consider squamous cell carcinoma of the nail unit (SCCNU) in each case of a nail abnormality unresponsive to topical treatment [23].

Procedural & Clinical Assessment: A simple procedure should be tried first in almost every case of paronychia, as many patients may be cured without recourse to nail removal [6]. Nail removal should be performed for the surgical treatment of chronic paronychia when concurrent nail irregularities are seen [21]. Severe paronychia can be treated by burning holes through the nail with a heated wire to drain pus [4]. 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 [29].

Other Considerations: Atypical chronic sterile paronychia can evolve and erode into the joint space in patients with thromboangiitis obliterans, driven by persistent inflammation, compromised vasculature, poor hand hygiene, poor healing, and reluctance to seek treatment [11]. Complications associated with mycobacterial hand infections can be significant [42]. Early osteomyelitis of the bone can be detected long before roentgenograms reveal evidence of destruction in closed space infections involving the distal phalanx [43]. The direct flow island flap is superior in terms of outcome for nail bed regeneration, regardless of age, sex, affected finger, dominant hand, type of trauma, and injury zone [28]. 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 [12]. The primary objective of the PVP-I trial was to evaluate efficacy as evidenced 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 [12]. Secondary objectives of the PVP-I trial assessed the impact on quality of life, the antimicrobial effect from baseline bacterial cultures, and nail clippings for fungus identification [12].

Treatment

Non-Operative Management

Topical or local therapy is an established treatment for fungal infections of the hand, including those involving the skin and nails [7]. For chronic paronychia, fluconazole at a dose of 50 mg/day is effective and safe [22]. In contrast, terbinafine shows no significant difference in efficacy compared to placebo in candidal nail disease after 12 weeks of therapy [33]. Alternative non-pharmacologic approaches include the nail polish sealer method, which was used to treat 59 patients with proved monilial paronychia [17]. Chemical sealing of the proximal nail fold with cyanoacrylate glue allows the gap between the proximal nail fold and nail plate to heal and fill within 6–8 weeks, providing relief from chronic paronychia [5]. Low-level laser therapy (LLLT) is also utilized, requiring an average of 20.4 ± 18.32 days to reach the treatment endpoint [10].

Operative and Procedural Management

Initial Intervention: A simple procedure of lifting the cuticle and inserting a sterile rubber ribbon should be tried first in almost every case of paronychia, as many patients may be cured without nail removal [6]. This technique can arrest and cure early paronychia in a few days without nail removal [40].

Drainage and Flap Techniques: A simple technique of draining acute paronychia can be used as a drainage procedure and part of the management of acute paronychia [39]. For chronic and severe acute paronychia with run-around infection involving both nail folds, the Swiss roll technique is a simple method [29]. The square flap technique cured paronychia in all but 2 cases, as measured by cuticle regrowth [34].

Clinical Course and Complications

Chronic paronychia typically presents with erythema, swelling, and pain, with symptoms present for more than 6 weeks at the time of diagnosis [18]. Episodic exacerbation of chronic paronychia symptoms can occur and may follow exposure to moist environments [18]. Atypical chronic sterile paronychia can evolve and erode into the joint space in patients with thromboangiitis obliterans due to persistent inflammation, compromised vasculature, poor hand hygiene, poor healing, and reluctance to seek treatment [11].

Complications

Infection: Chronic paronychia is an inflammatory disorder of the nail folds, commonly seen in housewives and housemaids, resulting from exposure to irritants and allergens [15].

Recovery

Light activity (weeks): Evidence does not specify a week range for return to desk work, driving, or light activities of daily living.

Full activity (months): Evidence does not specify a month range for return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): Chemical sealing of the proximal nail fold with cyanoacrylate glue results in healing and filling of the gap between the proximal nail fold and nail plate within 6–8 weeks, providing relief from chronic paronychia [5]. Low-level laser therapy (LLLT) for chronic paronychia required an average of 20.4 ± 18.32 days of therapy to reach the treatment endpoint [10].

Rehabilitation protocol: Evidence does not specify physical therapy phasing, immobilisation duration, weight-bearing or range of motion progression, or sling/brace removal timing.

Functional milestones: A novel topical povidone-iodine formulation (1% or 2%) was evaluated for efficacy in cancer therapy-associated paronychia, with the primary objective being a two-grade reduction on the Paronychia Severity Grading scale [12]. Candida eradication was not associated with clinical cure in most patients with chronic paronychia, indicating that Candida acts as a colonizer of the proximal nail fold rather than a primary pathogen [8].

Other Considerations: No additional recovery-relevant content, such as predictors of return-to-work failure or patient-selection caveats for early range of motion, is specified in the evidence.

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] 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. [9] (10.1159/000255443)
  • [L4] Chronic paronychia required on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint. [10] (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. [11] (10.1111/j.1440-0960.2012.00967.x)
  • [L2] [12] (10.1007/s10637-019-00825-0)
  • [L4] Chronic paronychia in children is predominantly associated with thumb-sucking, which causes maceration and creates a pocket for organisms like Candida albicans. [13] (10.1177/000992286800700213)
  • [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. [14] (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. [15] (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. [16] (10.1136/bmj.2.6200.1294-a)
  • [L4] Fifty-nine patients with proved monilial paronychia were treated with the nail polish sealer method. [17] (10.1001/archderm.1955.03730340045008)
  • [L5] [18] (10.5435/jaaos-22-03-165)
  • [L5] [19] (10.1016/j.jhsa.2013.11.017)
  • [L5] Candida paronychia is very uncommon except for patients with chronic mucocutaneous candidiasis and HIV infection, and its diagnosis can only be established on the basis of the results of treatment with systemic antifungals. [20] (10.5070/d32wb4g9wf)
  • [L4] Nail removal should be performed when concurrent nail irregularities are seen. [21] (10.1016/s0363-5023(10)80118-2)
  • [L4] These results show that 50 mg/day fluconazole is both effective and safe in the management of chronic paronychia. [22] (10.3109/09546639909056029)
  • [L4] Physicians should consider SCCNU in each case of a nail abnormality unresponsive to topical treatment. [23] (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. [25] (10.1097/00043764-196606000-00039)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [26] (10.1016/j.hcl.2020.03.002)
  • [L5] Hand infections include a diverse array of entities with potential for serious morbidity. [27] (10.1016/j.jhsa.2011.05.035)
  • [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. [28] (10.1177/15589447211064359)
  • [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. [29] (10.1097/bth.0b013e3181ec089e)
  • [L4] [30] (10.1001/archderm.1962.01590090066015)
  • [L5] [31] (10.1111/pde.15017)
  • [L5] [32] (10.1016/j.jhsa.2008.05.028)
  • [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. [33] (10.3109/09546639209088701)
  • [L4] The novel method cured paronychia in all but 2 cases, measured by cuticle regrowth. [34] (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. [35] (10.1016/j.jhsa.2014.03.031)
  • [L4] It can thus be used as drainage procedure and part of management of acute paronychia. [39] (10.1097/01.bth.0000163575.00615.69)
  • [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. [40] (10.1056/nejm192511051931904)
  • [L4] The complications associated with mycobacterial hand infections can be significant. [42] (10.1177/1558944720940064)
  • [L4] Early osteomyelitis of the bone can be detected long before the roentgenogram reveals evidences of destruction. [43] (10.1097/00000658-194001000-00013)
  • [L5] This review discusses the surface, gross, and microscopic anatomy of the distal digit to facilitate surgical procedures in the nail unit with minimal residual impact. [45] (10.1097/00042728-200103000-00009)
  • [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. [46] (10.1016/j.hcl.2020.03.012)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [47] (10.1016/j.hcl.2020.03.010)
  • [L4] Most hand infections are the result of minor wounds that have been neglected. [48] (10.1016/j.ijid.2005.06.009)
  • [L5] Proper direction of incisions helps ensure proper direction of healing, which determines whether scarring of the nail bed/matrix occurs. [49] (10.4103/jcas.jcas_67_23)
  • [L4] The distal phalanx has a dual blood supply, and removal of the major portion of the phalanx and preservation of the base will often give startling results in the regeneration of the phalanx. [51] (10.1001/archsurg.1942.01210240092006)

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

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

[11] 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

[12] 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

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

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

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

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

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

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

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

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

[21] Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80118-2

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

[23] 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

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

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

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

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

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

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

[31] Acute paronychia in a neonate secondary to clindamycin‐resistant Staphylococcus aureus. Pediatric Dermatology. 2022. DOI: 10.1111/pde.15017

[32] Current Management of Onychomycosis. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.05.028

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

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

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

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

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

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

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

[45] Surgical Anatomy of the Nail Unit. Dermatologic Surgery. 2001. DOI: 10.1097/00042728-200103000-00009

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

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

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

[49] Nail unit incision lines: A tool to minimize nail unit scarring. Journal of Cutaneous and Aesthetic Surgery. 2023. DOI: 10.4103/jcas.jcas_67_23

[51] END RESULTS OF A NEW INCISION FOR FELON (INFECTION OF THE ANTERIOR SPACE). Archives of Surgery. 1942. DOI: 10.1001/archsurg.1942.01210240092006

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Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

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.