eMedicine Specialties > Clinical Procedures > Soft Tissue Procedures

Hand, Paronychia Drainage

Noah Elise Gudel, DO, Resident in Internal Medicine, University of Tennessee Medical Center at Knoxville
Mohamad Marouf, MD, Consulting Staff, Department of Emergency Medicine, University Hospitals Health System, Richmond Heights Medical Center

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.

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.

Anesthesia

• Depending on the technique used, the procedure may be performed without anesthesia in most patients. Drainage of more complex lesions is best accomplished with a digital nerve block using 1-2% plain lidocaine or mepivacaine.⁵
• 
  

  

  In this case, the treating physician opted to use local anesthesia rather than a digital nerve block. In general, this is not preferred because of the limited subcutaneous space in which to inject the anesthetic.

  
  

Equipment

• Sterile field
• Blunt probe
• Scalpel, No. 11 or 15 blade
• Scissors
• Large syringe (30 mL)
• ZEROWET splash shield (ZEROWET, Palos Verdes Peninsula, Calif)
• Saline for irrigation
• Sterile gauze packing (plain or iodoform)
• Xeroform gauze

Positioning

• Both the patient and the physician should be comfortable.
• The patient should be supine, with the arm extended and the hand prone. A Mayo stand or carefully folded blanket on the bed can be used as armrests.

Technique

• Prepare a clean field, draping the finger and hand.

• The most simple and, often, least painful technique can be performed with only an 18-gauge needle. Anesthesia is not needed.
• The needle is positioned bevel up and laid horizontally on the nail surface. The needle 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 of mostly 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.

• For a complex incision and drainage (which is not often necessary), administer anesthesia via digital nerve block. A tourniquet may be used on the involved finger to limit bleeding. In the case pictured below, the treating physician opted to use local anesthesia rather than a digital nerve block.
• 
  

  

  Plain lidocaine is injected in a fan distribution until blanching is observed surrounding the area to be incised.

  
  
• 
  

  

  The local injection should be placed just proximal to the area to be incised.

  
  
• Soaking the eponychium to soften it may facilitate drainage.⁵
• The increased pressure from the local injection may cause spontaneous evacuation of pus.
• 
  

  

  The increased pressure from the injected local anesthetic causes some spontaneous evacuation of pus.

  
  
• 
  

  

  Spontaneous pus drainage after injection with local anesthetic.

  
  
• If nail fold involvement is limited, gently advance the scalpel under the eponychium and elevate it, with the blade directed away from the nail bed. Damage to the nail bed can result in future growth abnormalities, such as ridging of the nail.^6,11 The incision should be long enough to include the entire fluctuant area but no longer.¹
• 
  

  

  In this case, the wound was opened with a small incision using a No. 11 blade scalpel.

  
  
• If an underlying nail deformity such as an ingrown nail is present or if pus appears under any part of the nail, elevate one third of the nail on the side of the infection and make a longitudinal cut, removing that third of the nail. Use a small Halstead clamp or fine scissors to free the involved eponychium. Paronychia of the toes is often due to ingrown nails; this is not usually true of paronychia of the fingers.
• For proximal nail involvement, some physicians make a semilunar incision proximal to the nail fold instead of directly incising the cuticle and potentially causing a permanent injury.⁵
• If the infection involves more than a limited eponychium and paronychial fold, or if the nail is freely mobile, removal of the entire nail may be necessary.¹²
• Irrigate the wound with saline under pressure (ie, large syringe with ZEROWET splash shield attached).
• 
  

  

  Prior to packing or dressing the wound, irrigate the wound with normal saline under pressure using a splash guard, eye protection, or both.

  
  
• Explore the wound with a blunt probe, clamps, or the blunt end of a cotton swab. Evacuate as much pus as possible.
• 
  

  

  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.

  
  
• If a large pus collection is evacuated, pack the wound with plain or iodoform gauze tape for 24-48 hours to prevent reclosure and to assist drainage.^11,5 Packing may not be necessary as long as the incision extends the length of the abscess.¹
• Cover with Xeroform gauze and dress with dry 4 X 4 gauze.
• At 24-48 hours, the finger should be soaked and the packing removed. The patient can often do this himself or herself.
• Soak with saline for 15 minutes, 2-4 times daily, until healing occurs.¹²
• Antibiotic ointment or petroleum jelly may be used to keep the wound moist and prevent the bandaging from sticking to the wound.
• 
  

  

  The wound can be covered with antibiotic ointment or petroleum jelly to prevent bandage adhesion.

  
  
• Specialist follow-up is generally not necessary, as long as healing is occurring.

Pearls

• Epinephrine is not recommended in performing a digital block.¹³
• The use of a tourniquet while performing the digital nerve block may aid in hemostasis.^13,5
• Angle the scalpel away from the nail to avoid cutting the nail bed. Cutting the nail bed impacts later nail growth.^6,11
• An adequate incision is needed to facilitate the drainage of the entire abscess cavity. Note that the scalpel is only used to make the skin incision. Another instrument, such as a cotton swab or hemostat, should be used to drain the deep cavity.

Complications

• Allergic reaction to the anesthetic
• Osteomyelitis
• Treatment failure due to inadequate length of incision or failure to consider an atypical infecting agent such as herpes simplex virus or Candida albicans

ICD-9CM Code

681.9  Paronychia
681.11 Paronychia, toe I & D

Multimedia

Media file 1: 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.

Media file 2: This more lateral view shows that no pus or fluctuance is involved in the nail bed itself.

Media file 3: In this case, the treating physician opted to use local anesthesia rather than a digital nerve block. In general, this is not preferred because of the limited subcutaneous space in which to inject the anesthetic.

Media file 4: Plain lidocaine is injected in a fan distribution until blanching is observed surrounding the area to be incised.

Media file 5: The local injection should be placed just proximal to the area to be incised.

Media file 6: The increased pressure from the injected local anesthetic causes some spontaneous evacuation of pus.

Media file 7: Spontaneous pus drainage after injection with local anesthetic.

Media file 8: In this case, the wound was opened with a small incision using a No. 11 blade scalpel.

Media file 9: The wound can be explored with a blunt probe, clamps, or the blunt end of a cotton swab.

Media file 10: Ensure that all loculations are broken up and that as much pus as possible is evacuated.

Media file 11: Prior to packing or dressing the wound, irrigate the wound with normal saline under pressure using a splash guard, eye protection, or both.

Media file 12: The wound can be covered with antibiotic ointment or petroleum jelly to prevent bandage adhesion.

References

1. Office surgery. In: Rakel R, ed. Textbook of Family Practice. 6^th ed. Philadelphia, Pa: WB Saunders Company; 2002:663.

2. Hand. In: Marx J, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 1. 5^th ed. St. Louis, Mo: Mosby; 2002:529-30.

3. 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].

4. Opal S, Petropoulos P, Mikolich D, Ferri F. Ferri's Clinical Advisor: Instant Diagnosis and Treatment. Philadelphia, Pa: Mosby; 2008:667.

5. Roberts JR, Hedges JR. Incision and drainage. In: Clinical Procedures in Emergency Medicine. 4^th ed. Philadelphia, Pa: WB Saunders Company; 2004:738-41.

6. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. Mar 15 2001;63(6):1113-6. [Medline]. [Full Text].

7. Noble J. Textbook of Primary Care Medicine. 3^rd ed. St. Louis, Mo: Mosby; 2001:1167-68.

8. 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].

9. Clark DC. Common acute hand infections. Am Fam Physician. Dec 1 2003;68(11):2167-76. [Medline]. [Full Text].

10. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. Feb 1 2008;77(3):339-46. [Medline].

11. Hand infections. In: Canale ST, ed. Campbell's Operative Orthopaedics. Vol 4. 10^th ed. Philadelphia, Pa: Mosby; 2003:3810-13.

12. Halstead Residents of the Johns Hopkins Hospital. Chen H, Sonnenday C, Lillemoe K. Manual of Common Bedside Surgical Procedures. 2000:361.

13. 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

Contributor Information and Disclosures

Author

Noah Elise Gudel, DO, Resident in Internal Medicine, University of Tennessee Medical Center at Knoxville
Disclosure: Nothing to disclose.

Coauthor(s)

Mohamad Marouf, MD, Consulting Staff, Department of Emergency Medicine, University Hospitals Health System, Richmond Heights Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Thanks to Dr. Marouf at the Richmond Heights Emergency Department for his diligence in looking out for a case of paronychia drainage to photograph.

Griffiths G, Rocker M, Lewis MH, Gower-Thomas K. Paronychia or an abscess: early diagnosis. Hosp Med. 2004;65(11):696.

Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and Chronic Paronychia. Am Fam Physician. 2008 Feb 1;77(3):339-46.

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