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Acute Paronychia

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Acute Paronychia 12 EMN I November 2010 Fingertip Problems: InFocus Acute Paronychia By James R. Roberts, MD subacute infec- tion, characterized Part 2 in a Series Author Credentials Finan- by minor pain, cial Disclosure: James swelling, redness, soaking the finger, an antibiotic oint- R. Roberts, MD, is the Chair- and tenderness in ment and gauze dressing or small ban- man of the Department of Emergency the periungual dage are applied. Follow-up is not Medicine and the Director of the Divi- area, and without scheduled or required unless the condi- sion of Toxicology at Mercy Catholic obvious fluctu- tion worsens. X-rays, cultures, and lab Medical Center, and a Professor of ance, drainage, tests are unnecessary, although you Emergency Medicine and Toxicology at lymphangitis, or may want to check blood glucose. the Drexel University College of Medi- adenopathy. The The second scenario involves a cine, both in Philadelphia. Dr. Roberts history is usually more complicated or advanced condi- has disclosed that he is a member of not specific for an tion where conservative measures fail, the Speakers Bureau for Merck Phar- etiology, and the or the patient presents with frank pus. maceuticals. He and all other faculty process insidi- Often the purulence is obvious under and staff in a position to control the A classic paronychia with obvious pus in the eponychial ously develops for the skin, appearing as cream-colored content of this CME activity have dis- space. Do not incise the skin to drain this, but proceed no apparent rea- collection around the nail fold. In these as demonstrated in the accompanying pictures. closed that they and their spouses/life son. At this point, cases, surgical treatment is indicated. partners (if any) have no financial rela- the pathology is I hesitate to use the word “surgery” tionships with, or financial interests in, more in-depth review.) A paronychia is basically a cellulitis, but sometimes pus because this means “skin incision” to any commercial companies pertaining an acute (bacterial or herpetic) or had drained spontaneously or the brave most physicians. In this case, however, to this educational activity. chronic inflammation or infection of the patient performs self-treatment, and initial drainage can be accomplished periungual tissue. An acute bacterial the infection is already on the road to without an actual skin incision. Some of Learning Objectives: After participat- paronychia generally begins as a red, recovery. the older textbooks erroneously recom- ing in this activity, the physician hot, swollen, and tender area on the Patients in this category will likely mend incising the skin rather than the should be better able to: skin surrounding the proximal finger- respond to conservative treatment, and more reasonable approach of draining 1. Distinguish the pathophysiology of nail or toenail. the sagacious clinician defers drainage this localized pus collection by simply an acute bacterial paronychia. Clinically, it first appears as a attempts unless there is obvious pus. A lifting up the eponychium. A paronychia 2. Apply the best clinical approach cellulitis, and if left untreated can reasonable approach is to recommend is not an actual subcutaneous abscess, for treating early and developed progress to an abscess. Once pus has three to four days of a broad-spectrum like a boil or infected sebaceous cyst, paronychia. localized, drainage can be accom- antistaphylococcal antibiotic (amoxi- but a skin cellulitis over a collection of 3. Compose a differential diagnosis for plished relatively easily, and the patient cillin/clavulanate, dicloxacillin, clin- pus in a cavity under the cuticle. chronic paronychia. experiences a rapid cure. Many cases damycin, or cephalexin) in addition to Incising the dorsal skin of the epony- seem to develop spontaneously, but hot soaks. MRSA, a rampant skin infec- chium only compounds the injury, and is cute paronychia (synonymous some patients can recall an episode of tion, is usually not the culprit in these clearly not the way to drain pus from un- with perionychia) is a rather trauma, such as a puncture or hangnail. cases. When pus is absent, conservative der the cuticle. Incising the skin in the Acommon and annoyingly painful home care is the most reasonable fingertip of a diabetic can relegate him digital infection that frequently steers Comment: Reading the current medical course, and it usually works. In fact, to four to six weeks of slow healing. patients to the ED in search of relief. literature will leave the student with there is no surgery to recommend Contrast this to the few days’ healing Most infections are minor, and can be many unanswered questions, unproven unless pus is present; one is dealing with time associated with more conservative easily treated with conservative meth- therapeutic recommendations, and a simple cellulitis. I advise patients to procedures that avoid actual skin inci- ods, but occasionally surgical interven- incorrect approaches. I could not find a soak their affected finger in a coffee cup sion. Likewise, removing the fingernail, tion is required. single prospective study that compared filled with very hot tap water (not boiled as suggested by some authors, is gross Surprisingly little objective data and various treatment modalities. Most of water or sterile saline) for 10 minutes overtreatment for the first visit. Pus no prospective controlled trials exist in the articles in the literature are written four times a day, specifically eschewing from a paronychia rarely makes its way the medical literature dealing with the by hand surgeons who see complicated the patient-popular peroxide or alcohol. underneath the fingernail. The presence treatment of this common problem, prob- or advanced cases or family practition- It sounds simple enough, but it’s of a true subungual abscess may be an ably reflecting the fact that most patients ers who see mild or early cases. Both difficult for the layperson to soak indication for a nail removal, but this do quite well. Despite the fact that such base their treatment recommendations religiously. If you give patients some col- rarely occurs with a paronychia. patients are frequent denizens of the ED, on their skewed experience. ored antiseptic solution to add to the tap Some patients can tough out a non-emergency medicine reviews pre- Theoretically, for a paronychia to water, it may increase compliance be- physician gently lifting the cuticle, but dominate the literature. When dealing develop there is a break in the skin, cause it focuses attention on a bona fide I prefer to perform all drainage with a paronychia, as with any infection usually from a hangnail, puncture, or “medical procedure” of soaking in an an- procedures under a digital block with involving the hand, it is paramount for trauma, with local inoculation of bacte- tiseptic. Each time the finger is soaked, it long-acting bupivicaine. With a long- the clinician to know when to be aggres- ria. The infections are polymicrobial, should be for 10 minutes by the clock, acting anesthetic, caution the patient sive and when to be conservative. involving a number of aerobic and and the patient could take an oral antibi- that his finger should not be soaked in anaerobic organisms. Bacteria that otic four times a day. Long-acting antibi- hot water until sensation returns, to Paronychia normally inhabit the skin or mouth are otics are usually more patient-friendly, avoid thermal injury. (Or advise soaking Randell P usually found if the infection is cul- but coupling the antibiotic with soaking an adjacent unanesthetized finger at the Aust Fam Physician tured. Many patients with paronychias makes the soaking more likely to be same time.) 1985;14(5):377 bite their nails, suffer repeated minor done. Soaking and antibiotics may be Following digital block, I prefer to trauma, or have chronic skin conditions curative in this early stage of cellulitis. use a finger tourniquet. The eponychium Although brief and quite superficial, this or occupational predispositions. Many physicians, however, question (cuticle) is separated or lifted from the article discusses treating the common In the ED, it’s helpful to consider the the need for antibiotics at this stage, but underlying nail, exposing the potential acute and chronic paronychia. (See Am common acute bacterial paronychia in I tend to prescribe them unless the space that is now filled with pus. This is Fam Physician 2008;77[3]:339 for a two contexts. The first scenario is the process is obviously minor. After done atraumatically by gently teasing a InFocus November 2010 I EMN 13 1 4 2 5 1. To drain a paronychia, perform a digital block with bupivacaine. Apply a tourniquet and advance a #11 blade parallel to the nail. Lift up the cuticle, avoiding an actual incision. Pus should flow freely. 2. Place a hemostat into the eponychial space, and spread the tip to free up all remaining pus. Some will irrigate with saline at this point. 3. Pack the eponychial space with a small amount of gauze. It goes in more easily if moistened with saline or antiseptic solution. The benefit of iodinated gauze and the antiseptic solution over plain saline gauze is questionable. The patient can soak the finger in a coffee cup of very hot tap water three times a day. 4. Apply an antibiotic ointment (not containing neomycin) to the gauze. The pa- tient can remove the packing themselves (after it has been soaked and be- come wet) in 48 hours. After additional soaking, the cavity that has been created can be filled with antibacterial ointment for a few days. The value of ointment is likely minimal, but applying it focuses the patient’s attention on dressing changes and frequent wound evaluation. 5. A nice protective dressing is fluffy gauze covered with the finger of a latex glove. No tape is necessary.
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