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. [39, 40]
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. [41]
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.
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.
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.
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 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:
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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
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The skin of the nail fold is lifted, releasing pus from the paronychia cavity
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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
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Gentle pressure can be placed on the external skin to express any remaining pus from the paronychia
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The cavity can then be irrigated with saline
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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, 42] 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):
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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
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The proximal third of the nail is removed by using the method described for the no-incision technique
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After the abscess is drained, the pocket should be well irrigated with isotonic sodium chloride solution, packed with plain packing, and dressed
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The patient should receive oral antibiotics for 5-7 days
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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
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.
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:
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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
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All affected tissue within the boundaries of the crescent and extending down to, but not including, the germinal matrix is excised
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In effect, this procedure exteriorizes the infected and obstructed nail matrix and allows its drainage
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If the nail plate is grossly deformed at the time of surgery, it may be removed
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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.
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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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.
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In this case of paronychia, no pus or fluctuance is involved in the nail bed itself.
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Typical appearance of paronychia.
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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).
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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.
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Paronychia incision and drainage.
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Paronychial erythema and edema with associated pustule. This suggests a bacterial etiology.
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Paronychia, side view.
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After simple drainage, there is purulent return.
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Wound opened with a small incision using a number-11 blade scalpel.
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The wound can be explored with a blunt probe, clamps, or the blunt end of a cotton swab.
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Ensure that all loculations are broken up and that as much pus as possible is evacuated.
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Prior to packing or dressing the wound, irrigate the wound with normal saline under pressure, using a splash guard, eye protection, or both.
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The wound can be covered with antibiotic ointment or petroleum jelly to prevent bandage adhesion.
