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Home , Abscess, Boil, Cellulitis, Chancre, Hangnail, Paronychia

12 EMN I November 2010 Fingertip Problems: InFocus Acute

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 oint- R. Roberts, MD, is the Chair- and tenderness in ment and gauze 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 , 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 . 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 , 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 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 “” tionships with, or financial interests in, more in-depth review.) A paronychia is basically a , 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 or 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 , for treating early and developed progress to an abscess. Once pus has three to four days of a broad-spectrum like a or infected sebaceous , paronychia. localized, drainage can be accom- antistaphylococcal antibiotic (amoxi- but a skin cellulitis over a collection of 3. Compose a for plished relatively easily, and the patient cillin/clavulanate, , 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 . 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 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 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 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. 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 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

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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. Cut off the finger of the glove, and stretch it 3 and pull over the dressing. Give the patient a few gloves to take home for dressing changes. Don’t forget to remove the tourniquet! scalpel blade, scissor blade, or 18-gauge two days, but in my opinion, this is a outer layer of skin may or peel suspect MRSA or immunocompromise. needle into the nail fold. The instrument big mistake that only enhances skin within 48 to 72 hours of drainage. This is Complete cure is expected in a few days, is always kept parallel to the nail; the maceration and bacterial growth. not serious, but the dead skin should be so one fast-track visit usually suffices. skin is not actually incised. One merely Patients should be rechecked within debrided. Following removal of the pack- Toe paronychias are treated similarly. gently lifts the eponychium until there is 48 to 72 hours. The initial pack is then ing, there is usually a small cavity that re- There is no evidence that oral antibi- spontaneous flow of the pus. Once the removed and the wound inspected. mains open. It can be easily filled with an otics are necessary for the treatment of eponychium is loose, a blunt instru- Packing can usually be removed without antibiotic ointment, and covered with a uncomplicated, easily drained parony- ment, such as a hemostat (not the anesthesia after soaking in peroxide to gauze dressing. Soaking should continue chias in patients with normal immune scalpel) finishes the job by being swept soften the gauze. If the infection is well for another 2-3 days after the pack has systems. I may prescribe three to four from side to side to the base of the infec- on its way to recovery, forego additional been removed. Once the paronychia has days of antibiotic coverage to compli- tion to break up loculations. Irrigation of packing. If there is still considerable healed, the patient is advised to keep the ment local care if there is significant the cavity is probably not necessary, but drainage, the nail fold may be irrigated, periungual area dry and to use skin soft- induration. Ten days of the newest it’s a popular intervention. reopened, and packed a second time. eners to avoid cracking. I also advise third-generation or some A loose gauze pack is then placed in This may require another digital block. against biting the fingernails or removing similarly exotic, recently introduced the eponychial fold to ensure continued Some patients can remove the second with the teeth. antibiotic, is clearly unwarranted. Plain drainage. I advise the patient to begin pack themselves (after soaking at home) Adenopathy and lymphangitis are not old appears to be a reason- soaking (with the pack in place) as soon in another 24 hours, and follow-up is de- common, and if seen, may alter the rou- able first choice in most cases, based on as they get home. I have discovered that termined by clinical response or degree tine. X-rays, lab tests, and cultures are culture data, but in my experience, colleagues bandage this infected area, of patient anxiety. If the periungual skin not generally necessary, even if pus is ob- patients given any antibiotics seem to and tell the patient not to touch it for has been under significant pressure, an tained. Cultures may be supported if you Continued on next page 14 EMN I November 2010 InFocus

ACUTE PARONYCHIA Continued from previous page Creating a Differential Diagnosis for Chronic Paronychia do well. The antibiotic debate is unre- solved, but the key is to use reasonable Chronic paronychia: A chronic paronychia is a complex, multi- clinical judgment and not be dogmatic. factorial inflammatory reaction that develops in individuals whose Patients should be relatively have repeated exposure to moisture, irritants, allergens, or asymptomatic in three to five days. minor trauma. It can be considered a hand caused by Those who have recurrent problems environmental exposure. The initiating process separates the cuti- or do not respond adequately, espe- cle from the nail plate, rendering the area dry, irritated, and vul- cially if pus was drained, should be nerable to bacterial and fungal . The chronic form considered to have complicated infec- involves slow progressive swelling of the lateral or posterior bor- tions, possible , or an der of the nail folds and scarring associated with discoloration or unusual organism, and should be re- physical changes of the nail. Unlike the acute bacterial parony- ferred to a consultant. It’s probably chia, which generally involves a single finger, chronic infection a mistake to follow patients with can affect a number of fingers simultaneously. Prolonged local numerous members of an ED group treatment is generally curative, but referral is suggested. Once A chronic paronychia is a complex multifactorial for a number of weeks trying to cured, attention to local nail care can help prevent recurrence. condition, not just a simple fungal infection. This cure a smolderinginfection with each A chronic paronychia often represents an occupational prob- is best handled by a consultant, but the EP can new doctor’s favorite regimen. Com- lem, seen in laundry workers, house cleaners, dishwasher, chefs, prescribe a - cream from the ED, plications of a paronychia are fish handlers, and swimmers. Repeated exposure to trauma, wa- such as clotrimazole/betamethasone. Apply the cream and then an occlusive dressing, like the , extension to the flexor ter, or irritating chemicals is the culprit. albicans may be finger of a surgical glove. tendon (tenosynovitis) or fat pad area cultured, but the association between the organism and the (felon). Occasionally patients must be paronychia is not strictly causative and likely minimal. Consider underlying or in patients admitted for intravenous antibiotics or with proven Candida paronychia. Topical are often more effective than systemic (J Am Acad Derma- require more extensive surgery, but tol 2002;47[1]:73.) Chronic inflammation is difficult to eradicate, taking months to affect a cure. It’s best to refer such such cases should be the exception. patients. In the ED, one can take a fungal culture, and start an antifungal like ciclopirox or a steroid-antifungal like clotrimazole/betamethasone cream twice a day. Initially, withhold antibiotics and systemic antifungal therapy. Aerobic and Anaerobic Mimics: A chronic paronychia can resemble or Reiter’s disease. Tumors, such as squamous or of Paronychia malignant , , the primary of , , or foreign body reactions, can occasionally mimic a Brook I chronic paronychia. Ann Emerg Med 1990;19(9):994 HIV-related paronychia: Paronychia, especially of the great toe and associated with in- grown toenails, has been linked to retroviral therapy. Some HIV drugs such as lamivudine This report analyzes the microbiology have been reported to cause painful periungual of several nails during of 28 adult patients who underwent sur- treatment with these HIV drugs, developing months after starting treatment. (Br J Derma- gical drainage for a paronychia. Aerobic tol 1999;140[6]:1165; Clin Infect Dis 2001;32[1]:140.) Pyogenic granuloma, , and anaerobic cultures were obtained and extreme dry skin are associated. Antibiotics and surgical treatment may be required. by either swabbing the wound or by di- Children: Pediatric patients can develop a paronychia from sucking their fingers. The infec- rectly aspirating fluid. Careful culturing tion usually involves the fingers (especially the thumb and index finger), but the toes also techniques assured optimal anaerobic may be affected. (New Engl J Med 1970;283[15]:804; Arch Derm 1978;114[4]:567.) growth. Various culture media were Thumb-sucking is a frequent predisposition of chronic paronychia in children. (Clin Pediatr used to promote maximum recovery of [Phila] 1968;7[2]:104.) fastidious organisms. On average, 2.6 isolates per specimen were identified, Medical personnel: Medical personnel are at risk for herpetic paronychia (herpetic ). This is not a bacterial with 72 separate organisms being re- Although of no great clinical consequence, herpetic infections are slower to resolve, and should paronychia but a herpetic covered from the 28 specimens. A pure not be treated with overly aggressive incision or antibiotics. infections, character- whitlow, characterized by a culture of a single anaerobic organism ized by chronic paronychial inflammation and , have been reported rarely in painful, red, pruritic, - pathologists doing autopsies on infected cadavers. (Arch Derm 1978;114[4]:567.) ing, blistered area. They oc- was present in only five (18%) patients, cur in children with cold and a pure culture of a single aerobe in Final caveats: Failure to rapidly cure a paronychia should prompt specialized culture sores who suck their eight (29%). Mixed aerobic and anaero- techniques, proper referral, or occasionally a biopsy. One considers exotic organisms, os- thumb, herpes carriers, and medical personnel. Eschew bic cultures were the norm, and were teomyelitis, possible cancer, tuberculosis, occult foreign bodies, or immunocompromise found in 54 percent. There was no con- the temptation to drain this (especially AIDS). For the EP, a paronychia can be easily cured with minimal follow-up surgically; prescribe oral sistent pattern or combination of organ- required. If this is not the case, refer liberally for more in-depth evaluation. antivirals instead. isms. In four cases was cultured, and Eikenella corrodens was isolated in three patients. The author attempted to discuss the common found in parony- 20 percent incidence of pure anaerobic The authors conclude that parony- proper selection of antibiotics for these chias. However, staph (S. aureus or cultures, 27 percent pure aerobic cul- chias are usually infected with a mixed infections, but could not recom- S. epidermidis; no MRSA) was iso- tures, and 46 percent mixed aerobic number of mixed aerobic and anaero- mend an ideal empiric choice. Most lated in this study in only two of 72 cul- and anaerobic flora. In that report, bic organisms. The presence of aerobic pathogens isolated should theoretically tures. Clearly such infections are there were 3.6 isolates per specimen. bacteria is thought to be due to direct respond to cephalexin, , or polymicrobial, including aerobes, Numerous organisms were identified, inoculation of the fingers with mouth /clavulanate. The presence of anaerobes, and both gram-positive and including Candida albicans. flora, as can occur in biting the finger- anaerobic bacteria, some Gram negatives, gram-negative cocci and bacilli. Most nails or sucking the fingertips. The or- and E. corrodens make first-generation bacteria are along for the ride, not true ganisms recovered commonly colonize cephalosporin a less than perfect choice. pathogens. In a related study of the Only Online the oral cavity or skin, and interest- It is recommended that cultures be done bacteriology of paronychia in children ingly, a few cases of E. corrodens were if antibiotic therapy is contemplated. by the same author (Am J Surg Read all of Dr. Roberts’ past columns discovered. This organism accounts for 1981;141[6]:703), similar results were re- in the EM-News.com archive. some cases of human bite infections, COMMENT: Most textbooks state ported. Specimens from the paronychias and is also normal flora of the mouth. that staphylococci are the most of 33 children demonstrated a InFocus November 2010 I EMN 15

Reader Feedback: CME Participation Instructions Readers are invited o earn CME credit, you must read the article in Emergency Medicine Acknowledgment will be sent to you within six to eight weeks of participation. to ask specific TNews, and complete the evaluation questions and quiz, answering at Lippincott Continuing Medical Education Institute is accredited by questions and offer least 80 percent of the questions correctly. Mail the completed quiz with your the Accreditation Council for Continuing Medical Education to provide check for $12 payable to Lippincott Continuing Medical Education Institute, medical education to physicians. Lippincott Continuing Medical Educa- personal experi- Inc., Two Commerce Square, 2001 Market St., Third Fl., Philadelphia, PA 19103. tion Institute designates this educational activity for a maximum of 1 ences, comments, or observations Only the first entry will be considered for credit, and must be received AMA PRA Category 1 Credit.™ Physicians should only claim credit on InFocus topics. Literature refer- by Lippincott Continuing Medical Education Institute by November 30, 2011. commensurate with the extent of their participation in the activities. ences are appreciated. Pertinent re- November 2010 sponses will be published in a future Questions: issue. Please send comments to [email protected]. Dr. Roberts requests 1. What best distinguishes the pathophysiology an acute C. Incise the abscess via a dorsal skin incision. feedback on this month’s column, paronychia? D. Blood cultures, IV antibiotics, HIV testing, and admission. especially personal experiences with A. An intense local immunologic response to trauma and chronic inflammation. 4. Two weeks after his first autopsy, a pathology resident successes, failures, and technique. B. An acute bacterial infection of the nail fold followed develops a low-grade chronic paronychia with lym- by abscess formation under the cuticle. phadenopathy, but does not respond to two weeks of oral C. A sterile abscess of the fat pad and subungual space. antibiotics. Bacterial cultures are negative. Which of the Certainly no single antibiotic will D. An idiosyncratic local response to chemical irritants following should be considered mandatory? provide complete coverage for the array and moisture. A. Culture for mycobacterium. of bacterial and fungal pathogens B. Culture for herpes . 2. What is the best clinical approach for treating an early cultured from paronychias. Because C. Test for HIV. the vast majority of paronychias are paronychia without obvious abscess formation? D. Biopsy for melanoma. easily cured with simple drainage pro- A. Warm soaks and oral antibiotics. 5. What best describes the differential diagnosis for a cedures and local treatment, systemic B. Preemptive . chronic paronychia? antibiotics probably play little role in C. Systemic antifungals and topical steroids. D. Immediate referral to a hand surgeon. A. A fungal infection cured by long-term systemic anti- the cure. In fact, antibiotics are un- fungals. likely to be curative if one considers 3. What is the preferred treatment of a fluctuant acute B. A bacterial infection with MRSA. the polymicrobial nature of the infec- paronychia? C. Chronic inflammation due to irritants treated with tions. Because there are no prospective A. Lift up the cuticle, drain pus, and place packing. local corticosteroid cream. studies evaluating the true role of B. Warm soaks and oral antibiotics. D. Most likely a low-grade . antibiotic treatment of a drained paronychia, and no antibiotic will cover Directions 72 pathogens, this study clearly argues Your successful completion of this activity includes evaluating it. Please indicate your responses below filling in the blanks or by darkening the circles with a pencil or pen. against the routine use of any antibiotic. Please rate your confidence in your ability to achieve the following objectives, both before this activity and after it: Likewise, I see no reason to routinely 1 (minimally) to 5 (completely) Pre Post culture paronychial pus; how does one 12345 1 2345 interpret a report of three organisms, all Distinguish the pathophysiology of an acute bacterial paronychia. with a different antibiotic sensitivity? Apply the best clinical approach for treating early and developed paronychia. This infection is essentially an Compose a differential diagnosis for chronic paronychia. abscess, and there are good data Please indicate how well the activity met your expectations: 1 (minimally) to 5 (completely) 12345 Was effective in meeting the educational objectives demonstrating that antibiotics are of no Content was useful and relevant to my practice additive value for treating cutaneous Please address the practical application of this activity below that are adequately drained. How many of your patients may be affected by what you learned from this activity? ______In immunocompromised patients, Do you expect that the information you learned during this activity will help 12 345 particularly diabetics or those with pe- you improve your skill or judgment within the next 6 months? ripheral vascular disease or AIDS, can- (1-Definitely will not change, 5-Definitely will change) cer, or recurrent paronychia, a culture How will you apply what you learned from this activity? (Mark all that apply.) In diagnosing patients In making treatment decisions and antibiotics are probably warranted. In monitoring patients As a foundation to learn more I would not routinely culture a In educating students and colleagues In educating patients and their caregivers paronychia just because I was To confirm current practice As part of a quality/performance improvement project For maintaining board certification For maintaining licensure prescribing antibiotics. Unless one does Please complete these overall activity assessment questions. Yes No aerobic, anaerobic, fungal, and viral Did you perceive any bias for or against any commercial products or devices? cultures, the full benefit from this If yes, please explain: ______laboratory investigation will not be Compared with other educational activities in which you have participated 12345 gleaned, so why be only half-scientific? over the past year, how would you rate this activity? (1-Needs serious improvement, 5-A model of its kind) It is impossible to prospectively or empirically choose the proper antibiotic Future activities concerning this subject are necessary. 12345 (1-Strongly disagree, 5-Strongly agree) in all cases. Overall, amoxicillin/ My biggest clinical challenges related to this topic are: ______clavulanate seems like the best empiric Please use the space below to provide any additional information that will help the activity planners and faculty evaluate this activity. choice for the garden-variety parony- chia worthy of antibiotics. E. corrodens is a gram-negative rod I Yes, I am interested in receiving more information on this topic and future CME activities from Lippincott CME that is normal oral flora. It has been Institute. I am willing to help evaluate the outcomes of this activity. (Please place a check mark in the box.) reported to cause nasty infections Name ______from human bites. Biting the nails or sucking that hangnail likely precipitates Street Address ______an E. corrodens paronychia. This ______organism has an unusual sensitivity. It is ______sensitive to penicillin and , but resistant to oxacillin, methicillin, City ______State ______ZIP Code ______nafcillin, clindamycin, and often to Telephone ______E-mail ______cephalosporins.