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Paronychia Treatment & Management

  • Author: Elizabeth M Billingsley, MD; Chief Editor: William D James, MD  more...
 
Updated: Jun 06, 2016
 

Approach Considerations

The treatment of choice depends on the extent of the infection. If diagnosed early, acute paronychia without obvious abscess can be treated nonsurgically. If soft tissue swelling is present without fluctuance, the infection may resolve with warm soaks 3-4 times daily.[1, 3, 4]

Patients with extensive surrounding cellulitis or with a history of diabetes, peripheral vascular disease, or an immunocompromised state may benefit from a short course of antibiotics. An antistaphylococcal penicillin or first-generation cephalosporin is generally effective; clindamycin and amoxicillin-clavulanate are also appropriate.[5, 6]

If an abscess has developed, however, incision and drainage must be performed. Surgical debridement may be required if fulminant infection is present.[36, 37]

Herpetic whitlow and paronychia must be distinguished because the treatments are drastically different. Misdiagnosis and mistreatment may do more harm than good. Once herpetic whitlow is ruled out, one must determine whether the paronychia is acute or chronic and then treat it accordingly.[38]

Inpatient care

Admission for paronychia is rarely required unless associated with a significant cellulitis, tendonitis, or deep space infection of the hand requiring intravenous antibiotics.

Consultations

It is necessary to consult a hand surgeon if cellulitis, deep space infection, glomus tumor, mucous cyst, or osteomyelitis is suspected.

Long-term monitoring

Patients with recurring or chronic paronychia require frequent follow-up monitoring to prevent possible superinfections or deep-seated infections.

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Pharmacologic and Other Noninvasive Treatment

Acute paronychia

Warm water soaks of the affected finger 3-4 times per day until symptoms resolve are helpful.

Oral antibiotics with gram-positive coverage against S aureus, such as amoxicillin and clavulanic acid (Augmentin), clindamycin (Cleocin), or or cephalexin, are usually administered concomitantly with warm water soaks. (Although antibiotics are commonly prescribed,[1] most patients do not require antibiotics for a simple paronychia.)

Cleocin and Augmentin also have anaerobic activity; therefore, they are useful in treating patients with paronychia due to oral anaerobes contracted through nail biting or finger sucking. Cleocin should be used instead of Augmentin in patients who are allergic to penicillin.

If the paronychia does not resolve or if it progresses to an abscess, it should be drained promptly.

Chronic paronychia

The initial treatment of chronic paronychia consists of the avoidance of inciting factors such as exposure to moist environments or skin irritants. Keeping the affected lesion dry is essential for proper recovery. Choice of footgear may also be considered.

Any manipulation of the nail, such as manicuring, finger sucking, or attempting to incise and drain the lesion, should be avoided; these manipulations may lead to secondary bacterial infections.

Mild cases of chronic paronychia may be treated with warm soaks, followed by completely drying the digit. The initial medical treatment consists of the application of topical antifungal agents. Topical miconazole may be used as the initial agent. Oral ketoconazole or fluconazole may be added in more severe cases.

Patients with diabetes and those who are immunocompromised need more aggressive treatment because the response to therapy is slower in these patients than in others.

In cases induced by retinoids or protease inhibitors, the paronychia usually resolves if the medication is discontinued.

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Drainage

If paronychia does not resolve despite best medical efforts, surgical intervention may be indicated. Also, if an abscess has developed, incision and drainage must be performed (see the image below). Surgical debridement may be required if fulminant infection is present.

Paronychia incision and drainage. Paronychia incision and drainage.

Acute paronychia

No-incision technique

Less-advanced paronychial abscesses can be drained simply by gently elevating the eponychial fold from the nail by using a small blunt instrument such as a metal probe or an elevator (see the image below). This separation is performed at the junction of the perionychium and the eponychium and extends proximally enough to permit visualization of the proximal nail edge. Then, the proximal third of the nail can be excised with scissors and the pus evacuated.

Simple acute paronychia can be drained by elevatin Simple acute paronychia can be drained by elevating the eponychial fold from the nail with a small blunt instrument such as a metal probe or elevator.

This technique does not require an incision into the matrix. Often, no excision of any tissues is made, because only blunt dissection and separation are needed to evacuate the pus from the paronychia.

The wound should be well irrigated with isotonic sodium chloride solution, and plain gauze packing should be inserted under the fold to keep the cavity open and allow drainage.

The patient should receive oral antibiotics for 5-7 days. The packing is removed after 2 days, and warm sodium chloride solution soaks are begun.

Simple incision technique

The most simple and, often, least painful incision can be made without anesthesia, using only an 18-gauge needle. The technique is performed as follows:

  • The needle is positioned bevel up and laid horizontally on the nail surface; it is inserted at the lateral nail fold where it meets the nail itself, at the point of maximum fluctuance
  • The skin of the nail fold is lifted, releasing pus from the paronychia cavity
  • A gentle side-to-side motion may then be used to increase the size of the incision made by the needle, improving drainage; since the area incised is made up mostly of necrotic tissue, this is often painless
  • Gentle pressure can be placed on the external skin to express any remaining pus from the paronychia
  • The cavity can then be irrigated with saline
  • A small piece of 1/4-in gauze or iodoform tape can be inserted into the paronychia cavity for continued drainage. The wound is subsequently covered with a sterile bandage.

Single- and double-incision techniques

If the paronychia is more advanced, it may need to be incised and drained. A digital anesthetic block is usually necessary. If an anesthetic agent is used, it should consist of 1% lidocaine (Xylocaine).[4, 39] The local injection of the anesthetic agent into the paronychia or the wound is often inadequate and more painful than the administration of drugs of a digital block.

If the paronychia involves only 1 lateral fold of the finger, a single longitudinal incision should be placed with either a number-11 or number-15 blade directed away from the nail fold to prevent proximal injury and a subsequent nail growth abnormality. If both lateral folds of the finger are involved, incisions may be made on both sides of the nail, extending proximally to the base of the nail.

The next steps are as follows (see the images below):

  • After the single or double incision is made, the entire eponychial fold is elevated to expose the base of the nail and drain the pus
  • The proximal third of the nail is removed by using the method described for the no-incision technique
  • After the abscess is drained, the pocket should be well irrigated with isotonic sodium chloride solution, packed with plain packing, and dressed
  • The patient should receive oral antibiotics for 5-7 days
  • The dressing and packing are removed in approximately 2 days, and the affected finger is treated with warm soaks for 10-15 minutes 3-4 times per day
    Wound opened with a small incision using a number- Wound opened with a small incision using a number-11 blade scalpel.
    The wound can be explored with a blunt probe, clam The wound can be explored with a blunt probe, clamps, or the blunt end of a cotton swab.
    Ensure that all loculations are broken up and that Ensure that all loculations are broken up and that as much pus as possible is evacuated.
    Prior to packing or dressing the wound, irrigate t Prior to packing or dressing the wound, irrigate the wound with normal saline under pressure, using a splash guard, eye protection, or both.
    The wound can be covered with antibiotic ointment The wound can be covered with antibiotic ointment or petroleum jelly to prevent bandage adhesion.

Chronic paronychia

The most common surgical technique used to treat chronic paronychia is called eponychial marsupialization.

In this technique, the affected digit is first anesthetized with 1% lidocaine (Xylocaine), with no epinephrine, using the digital ring block method.

Tourniquet control of the proximal digit may be accomplished by using a finger of a latex glove with the distal end cut off or by using a sterile Penrose drain at the base of the digit firmly secured using a hemostat. The surgery proceeds as follows:

  • With a No. 15 blade, a crescent-shaped incision is made proximal to the distal edge of the eponychial fold; the distal incision is made approximately 1 mm proximal to the distal edge of the eponychium and extends along its curve. A curvilinear proximal incision is then made, extending from the lateral ends of the distal incision and forming a crescent with its widest margin approximately 5 mm from the distal incision; the incision should appear symmetrical
  • All affected tissue within the boundaries of the crescent and extending down to, but not including, the germinal matrix is excised
  • In effect, this procedure exteriorizes the infected and obstructed nail matrix and allows its drainage
  • If the nail plate is grossly deformed at the time of surgery, it may be removed
  • The excised region is packed with plain gauze wick, which is changed every 2-3 days

Epithelialization of the excised defect occurs over the next 2-3 weeks. Nail improvement occurs over the next 6-9 months but may require as long as 12 months to become apparent.

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Deterrence and Prevention

Patients should also avoid any further trauma to or manipulation of the nail. Hangnails should be trimmed to a semilunar smooth edge with a clean, sharp nail plate trimmer. Toenails should be trimmed flush with the toe tip. Patients should not bite the nail plate or lateral nail folds.

Patients should also avoid prolonged hand exposure to moisture. (Rubber or latex-free gloves can be worn.) If hand washing must be frequent, patients should use antibacterial soap, thoroughly dry their hands with a clean towel, and apply an antibacterial moisturizer.

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Contributor Information and Disclosures
Author

Elizabeth M Billingsley, MD Professor of Dermatology, Pennsylvania State University College of Medicine; Director, Mohs Micrographic Surgery, Penn State Hershey Medical Center

Elizabeth M Billingsley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, Association of Professors of Dermatology, Council for Nail Disorders, Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Allison T Vidimos, MD, RPh Chair, Department of Dermatology, Vice Chair, Dermatology and Plastic Surgery Institute, Staff Physician, Department of Dermatology and Dermatologic Surgery and Cutaneous Oncology, Cleveland Clinic; Professor of Dermatology, Department of Medicine, Case Western Reserve University School of Medicine

Allison T Vidimos, MD, RPh is a member of the following medical societies: American Academy of Dermatology, Association of Professors of Dermatology, International Transplant and Skin Cancer Collaborative, American College of Mohs Surgery, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery

Disclosure: Partner received grant/research funds from Genentech for none.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Yelena Bogdan Stony Brook University Health Sciences Center School of Medicine (SUNY)

Disclosure: Nothing to disclose.

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Noah Elise Gudel, DO Resident in Internal Medicine, University of Tennessee Medical Center at Knoxville

Disclosure: Nothing to disclose.

Micelle J Haydel, MD Associate Clinical Professor of Medicine, Residency Director, Section of Emergency Medicine, Louisiana State University Health Science Center

Micelle J Haydel, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Association, Sigma Theta Tau International, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Mark F Hendrickson, MD Chief, Section of Hand Surgery, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

Steve Lee, MD Physician in Plastic, Reconstructive, and Hand Surgery, Plastic Surgery, PLLC

Steve Lee, MD is a member of the following medical societies: American College of Surgeons and American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Mohamad Marouf, MD Consulting Staff, Department of Emergency Medicine, University Hospitals Health System, Richmond Heights Medical Center

Disclosure: Nothing to disclose.

Heather Murphy-Lavoie, MD, FAAEM Assistant Professor, Assistant Residency Director, Emergency Medicine Residency, Associate Program Director, Hyperbaric Medicine Fellowship, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine in New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine

Heather Murphy-Lavoie, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Jerome FX Naradzay, MD, FACEP Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina

Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Julia R Nunley, MD Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center

Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Richard K Scher, MD Adjunct Professor of Dermatology, University of North Carolina; Professor Emeritus of Dermatology, Columbia University

Richard K Scher, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, American Dermatological Association, American Medical Association, Association of Military Surgeons of the US, International Society for Dermatologic Surgery, Noah Worcester Dermatological Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeter (Jay) Pritchard Taylor III, MD Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Classic presentation of paronychia, with erythema and pus surrounding the nail bed. In this case, the paronychia was due to infection after a hangnail was removed.
In this case of paronychia, no pus or fluctuance is involved in the nail bed itself.
Typical appearance of paronychia.
Depicted are the nail fold (A), dorsal roof (B), ventral floor (C), nail wall (D), perionychium (E), lunula (F), nail bed (G), germinal matrix (H), sterile matrix (I), nail plate (J), hyponychium (K), distal groove (L), fascial septa (M), fat pad (N), distal interphalangeal joint (O), and extensor tendon insertion (P).
Simple acute paronychia can be drained by elevating the eponychial fold from the nail with a small blunt instrument such as a metal probe or elevator.
Paronychia incision and drainage.
Paronychial erythema and edema with associated pustule. This suggests a bacterial etiology.
Paronychia, side view.
After simple drainage, there is purulent return.
Wound opened with a small incision using a number-11 blade scalpel.
The wound can be explored with a blunt probe, clamps, or the blunt end of a cotton swab.
Ensure that all loculations are broken up and that as much pus as possible is evacuated.
Prior to packing or dressing the wound, irrigate the wound with normal saline under pressure, using a splash guard, eye protection, or both.
The wound can be covered with antibiotic ointment or petroleum jelly to prevent bandage adhesion.
 
 
 
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