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Hand Infections Follow-up

  • Author: Jordan Scaff, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Jan 11, 2016
 

Further Outpatient Care

Paronychia

Instruct the patient with acute paronychia to soak the affected finger 3-5 times per day in warm water.

If a wick was placed, the patient usually can remove it easily after 24 hours if it has not fallen out already.

Schedule follow-up care with the primary care doctor or at the ED for 48 hours after initial incision.

Antibiotics, if prescribed, should be continued for 3-5 days.

In cases of chronic paronychia, topical steroids and antifungal agents should be initiated.

Pain medication may be prescribed as indicated.

Felon

Reevaluate the wound 48 hours after initial incision.

At this time, remove the packing and irrigate the wound.

If continued drainage is present, loosely repack the wound and schedule another follow-up appointment in 24 hours.

If no further drainage is present, repacking is unnecessary.

Instruct the patient to keep the wound clean by washing it twice daily with warm, soapy water followed by a clean gauze dressing.

The patient should continue antibiotics for 5-7 days.

Pain medication may be prescribed as indicated.

Herpetic whitlow

Instruct the patient to keep the affected area clean and covered with a dry dressing to prevent further transmission of the virus.

Oral acyclovir may be involved in preventing recurrence or in immunocompromised patients.

Pain medication may be prescribed as indicated.

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Further Inpatient Care

Patients with evidence of infectious tenosynovitis or deep fascial space infections require inpatient treatment consisting of parenteral antibiotics and definitive incision and drainage by an experienced hand surgeon.

Inpatient splinting and occupational therapy for range of motion is essential to preserve function.

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Transfer

Emergency medicine physicians should feel competent and comfortable with the treatment of paronychia, felons, and herpetic whitlow.

Because of the specialized care required for infectious tenosynovitis and deep fascial space infections, transfer of patients with such infections may be necessary if those services are not available at the presenting hospital.

Prior to transfer, splint the affected area, update tetanus booster as needed, and initiate antibiotic therapy.

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Deterrence/Prevention

All care should be taken to avoid manicures or other salon procedures with unclean implements. Proper hand hygiene should be observed.[8]

All wounds and abrasions to the hand should be taken seriously and thoroughly cleaned and dressed until healed. Careful observation and prompt medical evaluation prevents complications.

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Complications

Paronychia

See the list below:

  • Subungual abscess
  • Osteomyelitis of the distal phalanx
  • Development of a felon
  • Chronic infection

Felon

See the list below:

  • Osteomyelitis of the distal phalanx
  • Skin pulp necrosis
  • Sinus tract formation
  • Septic joint
  • Tenosynovitis
  • Inappropriate incision and drainage technique, resulting in sensory loss, tendon injury, spread of infection, or instability of the finger pad

Herpetic whitlow

See the list below:

  • Oral inoculation or transmission of virus
  • Inappropriate treatment (eg, misdiagnosed as a felon) with incision and drainage, allowing viral spread into healthy tissue
  • Viremia occurrence possible

Infectious tenosynovitis

See the list below:

  • Tendon destruction
  • Functional disability
  • Extension of infection to deep fascial space

Deep fascial space infection

See the list below:

  • Functional disability
  • Tendon destruction
  • Sepsis
  • Hand loss
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Prognosis

Paronychia

Most resolve in 2-4 days.

Chronic infections are likely fungal infections and are typically more difficult to treat.

Felon

The prognosis is good, with healing in 1-2 weeks.

Herpetic whitlow

Infection usually resolves in 2-4 weeks.

Recurrence is not uncommon because virus may lay dormant in neural ganglia.

Infectious tenosynovitis and/or deep fascial space infection

These have a fair prognosis, depending on the extent of tissue destruction, bony involvement, preexisting vascular insufficiency, and systemic complications (eg, bacteremia, sepsis).

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Patient Education

See the list below:

  • Instruct patients on proper wound care including warm soaks, if indicated, and dressing changes.
  • Inform patients of the signs and/or symptoms of worsening infection, including increased pain, edema, redness, warmth, or fever.
  • Emphasize the importance of follow-up care and wound reevaluation with the primary medical doctor or the ED physician.
  • Instruct patients to avoid predisposing factors, such as nail biting, manicuring, and repeated exposure to water and/or irritants.[9]
  • For excellent patient education resources, visit eMedicineHealth's Infections Center. Also, see eMedicineHealth's patient education articles Paronychia (Nail Infection), Finger Infection, Hand Injuries, and Finger Injuries.
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Contributor Information and Disclosures
Author

Jordan Scaff, MD Resident Physician, Department of Emergency Medicine, Mount Sinai Beth Israel

Jordan Scaff, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Gregory S Johnston, MD Assistant Professor of Emergency Medicine, Mount Sinai Beth Israel

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Rohini J Haar, MD Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center

Rohini J Haar, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Amy K Rontal, MD, and Heatherlee Bailey, MD, to the development and writing of this article.

References
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  9. Ergun A, Toprak R, Sisman FN. Impact of a Healthy Nails Program on Nail-Biting in Turkish Schoolchildren: A Controlled Pretest-Posttest Study. J Sch Nurs. 2013 Mar 14. [Medline].

  10. Antosia RE, Lyn E. Hand. Rosen, ed. Emergency Medicine Concepts and Clinical Practice. 5th ed. 2002. 493-535.

  11. Butler, KH. Incision and drainage. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. 2004. 739-744.

  12. Daniel CR 3rd, Daniel MP, Daniel J, Sullivan S, Bell FE. Managing simple chronic paronychia and onycholysis with ciclopirox 0.77% and an irritant-avoidance regimen. Cutis. 2004 Jan. 73(1):81-5. [Medline].

  13. Gill MJ, Arlette J, Buchan K. Herpes simplex virus infection of the hand. A profile of 79 cases. Am J Med. 1988 Jan. 84(1):89-93. [Medline].

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  17. Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999 Jan 14. 340(2):85-92. [Medline].

  18. Wolanyk DE. 17. Infections. Hart RG, Uehara DT, Wagner MJ, eds. Emergency and Primary Care of the Hand. Irving,Tx: The American College of Emergency Physicians; 2001. 219-246.

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A paronychia can progress to a felon if left untreated.
A herpetic whitlow. Image courtesy of Glen Vaughn, MD.
Paronychia incision and drainage.
 
 
 
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