eMedicine Specialties > Clinical Procedures > Soft Tissue Procedures
Hand, Paronychia Drainage
Updated: Nov 10, 2009
Introduction
A paronychia is a soft tissue infection that is localized to the proximal or lateral nail fold,1 though it may also spread to the surrounding subcutaneous tissue or under the entire nail. It begins as a cellulitis but may progress to a definite abscess.2 It may be either acute or subacute. As subacute paronychias never require surgical intervention, further discussion here is unwarranted.
Classic presentation of a paronychia, with erythema and pus surrounding the nail bed. In this case, the paronychia was due to infection after a hangnail was removed.
This more lateral view shows that no pus or fluctuance is involved in the nail bed itself.
Chronic paronychias may actually represent a dermatitis of the nail fold, and despite frequent colonization with bacteria and fungi, respond best to topical steroid preparations.3 Acute paronychias are the most common infection of the hand, and they affect males and females equally. They most often occur in children and are usually limited to one finger (most often the thumb).4 Poor hygiene and trauma to the proximal or lateral nail fold, such as that from hangnails, nail biting, or thumb-sucking, can cause an acute paronychia, which presents as an erythematous painful swelling around the nail fold.
The most common pathogen in adults is Staphylococcus aureus (though Streptococcus pyogenes, Enterococcus faecalis, and Proteus and Pseudomonas species can also be involved),4 and infections in children are often due to mixed oropharyngeal flora (due to thumb-sucking and fingernail biting).5
If soft tissue swelling is present without fluctuance, the infection may resolve with warm soaks 3-4 times daily and a short course of antistaphylococcal antibiotics.5,6 Once any sign of abscess formation appears, such as fluctuance or visible pus, surgical intervention is indicated.7
The definitive treatment for an acute paronychia is drainage. Though antibiotics are commonly prescribed,2 most patients do not require antibiotics for a simple paronychia. A review of Medline from 1966 through 2005 provided no evidence that surgical management is more advantageous than oral antibiotics for the treatment of acute paronychia.8 Those with extensive surrounding cellulitis or with a history of diabetes, peripheral vascular disease, or 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.6,9 Wound cultures are not generally necessary in minor nonrecurrent infection. Tetanus status should be assessed, and a booster given, if appropriate.9
The differential diagnosis of paronychia is wide, including such entities as amelanotic melanoma, squamous cell carcinoma, viral infection, and adverse effects of various chemotherapeutic regimens.10 Failure of a suspected infectious or inflammatory process to improve with standard therapies should prompt reevaluation, and biopsy should be considered.
Indications
- Indication of abscess formation, such as fluctuance
- Nail bed mobility (indicates that the infection has extended under the nail)
Contraindications
- No absolute contraindications exist.
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References
Office surgery. In: Rakel R, ed. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders Company; 2002:663.
Hand. In: Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 5th ed. St. Louis, Mo: Mosby; 2002:529-30.
Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. Jul 2002;47(1):73-6. [Medline].
Opal S, Petropoulos P, Mikolich D, Ferri F. Ferri's Clinical Advisor: Instant Diagnosis and Treatment. Philadelphia, Pa: Mosby; 2008:667.
Roberts JR, Hedges JR. Incision and drainage. In: Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders Company; 2004:738-41.
Rockwell PG. Acute and chronic paronychia. Am Fam Physician. Mar 15 2001;63(6):1113-6. [Medline]. [Full Text].
Noble J. Textbook of Primary Care Medicine. 3rd ed. St. Louis, Mo: Mosby; 2001:1167-68.
Shaw J, Body R. Best evidence topic report. Incision and drainage preferable to oral antibiotics in acute paronychial nail infection?. Emerg Med J. Nov 2005;22(11):813-4. [Medline].
Clark DC. Common acute hand infections. Am Fam Physician. Dec 1 2003;68(11):2167-76. [Medline]. [Full Text].
Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. Feb 1 2008;77(3):339-46. [Medline].
Hand infections. In: Canale ST, ed. Campbell's Operative Orthopaedics. Vol 4. 10th ed. Philadelphia, Pa: Mosby; 2003:3810-13.
Halstead Residents of the Johns Hopkins Hospital. Chen H, Sonnenday C, Lillemoe K. Manual of Common Bedside Surgical Procedures. 2000:361.
Gmyrek R. Local anesthesia and regional nerve block anesthesia. eMedicine from WebMD. Updated August 7, 2009. Available at emedicine.medscape.com/article/1127490-overview. Accessed December 22, 2007.
Keywords
paronychia drainage, drain paronychia, paronychia, paronychial infection, inflammation of nail fold, infection of the hand, finger infection, toe infection, onychia lateralis, onychia periungualis, digital nerve block, incision and drainage, I & D, felon, ingrown nail, subungual hematoma, subungual abscess, onychocryptosis, closed-space infections, fingertip pulp, hand infections, osteomyelitis, tenosynovitis, septic arthritis, infection, infection, nail bed infection, nailbed infection
