ABSTRACT
BACKGROUND: Although Candida is often isolated from nails afflicted with chronic paronychia, the benefit of treating chronic paronychia with antifungal agents has never been proved. More recently, chronic paronychia is thought to be an eczematous condition better treated with corticosteroids.
POPULATION STUDIED: A total of 45 patients, 22 to 69 years of age, presenting to a dermatology clinic in Italy with chronic paronychia were enrolled. The diagnosis of chronic paronychia was established by the following criteria: absence of the cuticle with swelling and erythema of the proximal nail fold. Exclusion criteria included hypersensitivity to imidazoles or terbinafine, use of drugs interfering with itraconazole or terbinafine metabolism, pregnancy, liver or renal dysfunction, history of contact dermatitis from steroids, onychomycosis, psoriasis, lichen planus, and self-induced or manicure-related nail abnormalities. Disease duration before the study ranged from 1 month to 40 years (mean 2.3 years).
STUDY DESIGN AND VALIDITY: Patients were randomized in a double blind fashion to receive either itraconazole 200 mg daily; terbinafine 250 mg daily; or topical methylprednisolone aceponate cream 0.1%, 5 mg daily. Treatment duration was 3 weeks and patients were followed for an additional 6 weeks. Mycological samples were obtained and a clinical examination performed at baseline, the end of treatment, and the end of follow-up. Nail abnormalities were rated as cured (regrowth of cuticle with normal proximal nail fold), improved (proximal nail fold not inflamed, absence of cuticle, nail plate growing normally), stable (proximal nail fold still inflamed), or worsened (acute flare with purulent inflammation of the proximal nail fold).
OUTCOMES MEASURED: The primary outcomes measured were the presence of Candida in the proximal nail fold and the clinical status of nails and patients at the end of the follow-up period. No measure of patient satisfaction was determined.
RESULTS: The 3 groups were similar at baseline in terms of sex, age, and number of fingernails affected by chronic paronychia. A total of 42 patients (93%) completed 6 weeks of follow-up. The presence of Candida was not linked to disease activity; mycological examination before treatment revealed the presence of Candida in the proximal nail fold of only 18 of 45 patients. Only 2 of these patients had simultaneous eradication of Candida and clinical cure by the end of the study, both of whom were in the topical steroid group. Clinical improvement or cure of total nails at the end of follow-up was superior with topical steroids compared with either terbinafine or itraconazole (85% vs 53% vs 45%; P < .01; NNT = 3 and 2.5, respectively). Improvement or cure was observed in 60% of patients treated with topical steroids compared with 33% treated with itraconazole and 20% treated with terbinafine.
In this small but well-designed study, topical steroids were more effective than systemic antifungal agents in the treatment of chronic paronychia. Given their lower risks and costs compared with systemic antifungals, topical steroids should be the first treatment offered to patients with chronic paronychia. Although Candida is often isolated from these nails, its presence or absence appears to be unrelated to effective treatment of this disorder.