What is the diagnosis and treatment for a dishwasher with redness, scaling, mild swelling along the nail fold, erythema of the proximal nail fold, and absence of cuticle?

Chronic Paronychia with Secondary Nail Dystrophy

This dishwasher has chronic paronychia with secondary nail dystrophy caused by chronic moisture exposure, and treatment requires strict avoidance of wet work combined with topical corticosteroids—not antifungals—as the primary therapy.

Diagnosis

The clinical presentation is pathognomonic for chronic paronychia:

• Redness, scaling, and mild swelling of the nail fold with erythema of the proximal nail fold and absent cuticle are classic features of chronic paronychia, which occurs specifically in patients with wet occupations such as dishwashers 1

• The cuticle detachment from chronic water immersion creates a breach in the protective nail barrier, allowing microorganisms (both yeasts and bacteria) to enter the subcuticular space, perpetuating a vicious cycle of inflammation 1

• This is fundamentally an irritant contact dermatitis, not primarily an infectious process, despite the common misconception that it requires antifungal therapy 2, 3

• Chronic paronychia is defined by symptoms lasting at least 6 weeks 2, 3

Key Diagnostic Pitfall

Do not confuse this with onychomycosis—fungal nail infections present with nail plate thickening, discoloration, and friable texture developing over weeks to months, not acute proximal nail fold inflammation with cuticle loss 4. The occupation (dishwasher) and clinical pattern (proximal nail fold inflammation with absent cuticle) clearly indicate chronic paronychia 1.

Treatment Algorithm

First-Line Therapy (Essential)

1. Occupational modification is paramount and non-negotiable 2, 3:

   • Avoid excessive moisture exposure completely 2, 4
   • Wear protective waterproof gloves when working with water or chemicals 2, 4
   • Apply daily topical emollients to cuticles and periungual tissues 2, 4

2. Mid-to-high potency topical corticosteroid ointment applied to nail folds twice daily 2, 3:

   • This addresses the underlying inflammatory process
   • Topical steroids are more effective than systemic antifungals for chronic paronychia 5, 6

3. Dilute vinegar soaks (50:50 dilution with water) twice daily for 10-15 minutes 2, 3:

   • Alternative to warm water soaks
   • Helps reduce secondary bacterial colonization

Second-Line Therapy (If First-Line Fails)

• Topical calcineurin inhibitors can be used as steroid-sparing agents 3

• Intralesional triamcinolone acetonide for recurrent or severe cases 2

Surgical Options (Recalcitrant Cases Only)

• En bloc excision of the proximal nail fold 5, 6, 3
• Eponychial marsupialization with or without nail plate removal 5, 6, 3

Critical Management Points

Treatment may take weeks to months to achieve resolution 3. The inflammation and fibrosis of the proximal nail fold with poor cuticle regeneration creates ongoing vulnerability to irritants 6.

What NOT to Do

• Do not use systemic antibiotics routinely—they are ineffective unless proven infection is present 7, 3
• Do not prescribe systemic antifungals as primary therapy—while up to 25% of cases have secondary fungal colonization, the underlying problem is inflammatory, not infectious 2, 6
• Do not treat without addressing occupational exposure—failure to modify wet work exposure will result in treatment failure regardless of medication used 2, 3

When to Consider Cultures

Culture purulent material only if an abscess is present to guide antibiotic therapy 2. Remember that secondary bacterial or mycological colonization occurs in up to 25% of cases but does not change the primary treatment approach 2.

Prevention of Recurrence

Patient education is the cornerstone of preventing recurrence 2, 3:

• Avoid nail-biting and cutting nails too short 2
• Gentle skin care and avoidance of repeated friction/trauma 2
• Regular application of emollients to maintain the protective nail barrier 2, 4
• Consider career counseling if occupational modification is impossible, as chronic moisture exposure will perpetuate the condition 3