eMedicine Specialties > Emergency Medicine > Infectious Diseases
Paronychia: Treatment & Medication
Updated: Oct 8, 2008
- Overview
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Treatment
Prehospital Care
The patient with a paronychia is typically ambulatory. Splinting the finger with clean gauze is necessary to decrease discomfort until definitive treatment is rendered.
Emergency Department Care
- The treatment of choice for a paronychia is incision and drainage.18
- Provide warm compresses or soaks with half-strength hydrogen peroxide.
- Elevate the infected nail.
- Keep fingers clean and dry.
- Incision and drainage
- Incision and drainage are not indicated for herpetic whitlow (the most common infection mistaken for paronychia), mucous cyst, glomus tumor, and osteomyelitis.
- For maximum patient comfort, the digit is anesthetized with an appropriate digital nerve block.
- The nail plate and surrounding skin are cleaned with an appropriate antiseptic agent. Blunt dissection with the tip of a sharp instrument or point of a surgical blade is used to elevate the lateral nail fold. The operator attempts to enter the sulcus between the lateral nail plate and lateral epithelium. Purulent drainage can erupt when the sulcus is entered by the instrument tip. The lateral fold of skin should be elevated slightly and irrigated with isotonic sodium chloride solution using a catheter tip syringe.
- A "run-around" describes a severe paronychia that extends along the medial and lateral nail edges. In such cases, or when a large paronychia is present, the cavity should be splinted open with a small wick to prevent adhesion and reformation.
- If purulence has tracked under the nail, excision of the ipsilateral nail may be necessary.
- The presence of a subungual abscess (ie, "floating nail") requires nail plate removal. The degree of debridement is commensurate with the degree of nail bed infection.
- The presence of a finger pulp abscess or felon may require an additional incision of the pad of the finger tip to adequately drain. Be careful to avoid the neurovascular bundles that run on the lateral edges of the finger.
Consultations
It is necessary to consult a hand surgeon if cellulitis, deep space infection, glomus tumor, mucous cyst, or osteomyelitis is suspected.
Medication
Antibiotics are not necessary if the incision successfully achieves adequate drainage and no cellulitis is present. Most paronychia infections can be managed without antibiotics. Over-the-counter analgesics are usually sufficient. If cellulitis is present, antibiotics are indicated. Penicillin is probably the first-line agent, covering oral flora well. In consideration of allergies and contraindications, an oral cephalosporin agent may be considered for outpatient treatment. Clindamycin may be considered to cover methicillin-resistant Staphylococcus aureus and anaerobic organisms. Combination therapy with an IV agent that provides antimicrobial activity against staphylococci is used for inpatient therapy. See Hand Infections for a detailed discussion of antibiotics.
Chronic paronychial infections are usually managed with oral antifungals such as ketoconazole, itraconazole, or fluconazole.16 This is beyond the scope of emergency medicine practice since many of these agents require a prolonged course with monitoring of laboratory tests to avoid complications.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting.
Clindamycin (Cleocin)
Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
Adult
300 mg PO qid
Pediatric
10-25 mg/kg/d PO divided qid for 10 d
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Penicillin VK (Beepen-VK, Betapen-VK, Pen.Vee K, Robicillin VK, V-Cillin K, Veetids)
Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached, and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.
Adult
500 mg PO tid/qid for 10d
Pediatric
<12 years: 25-50 mg/kg/d PO divided tid/qid up to 3 g/d
>12 years: Administer as in adults
Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment
Cephalexin (Keflex)
First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora. Used for skin infections or prophylaxis in minor procedures.
Adult
500 mg PO qid for 7-10 d
Pediatric
25-50 mg/kg PO divided qid; not to exceed 4 g/d
Coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
More on Paronychia |
| Overview: Paronychia |
| Differential Diagnoses & Workup: Paronychia |
 Treatment & Medication: Paronychia |
| Follow-up: Paronychia |
| Multimedia: Paronychia |
| References |
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References
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Further Reading
Keywords
paronychia, finger infection, paronychial infection, onychia lateralis, onychia periungualis, inflammation of the nail fold, incision and drainage, I and D, I&D, paronychia, nail infection, superficial infection of the epithelium, staphylococci, infection of the hand, eponychia, felon, runaround abscess, herpetic whitlow, chronic paronychia, acute paronychia
