Hand Infections Treatment & Management

Updated: Jun 06, 2018
  • Author: Eden Kim, DO; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Treatment

Emergency Department Care

Paronychia

In acute paronychia, if no frank abscess or fluctuance is noted along the lateral nail edge, frequent hot soaks and possibly a short course of antibiotics may result in resolution of the infection.

If pus is present, drainage of the area is required. Using a No 11 scalpel blade held parallel to the nail, elevate the lateral nail fold at the site of the abscess to allow for drainage of pus. If a large amount of pus is expelled, a small wick is left in the incision to allow for continued drainage. If pus has tracked beneath the nail, the removal of an adjacent longitudinal section of the nail may be necessary to promote drainage. If a subungual abscess results in a floating nail, remove a portion of the nail or trephinate the nail to allow for complete drainage.

Elevation of the eponychial fold with a No 11 blade is quick, usually painless, and effective. If there is pain, it is extremely brief, less so than the pain of a digital block, so local anesthesia is typically unnecessary. Discuss the procedure with the patient to alleviate his or her fears. Extensive incision or penetration of the finger with the blade is unnecessary; simple elevation of the fold will do; therefore, no nerve block is needed. If the patient requests it, a digital nerve block can be performed for comfort.

After drainage and wick placement, dress the finger appropriately.

Update tetanus booster status as needed.

In chronic paronychia, treatment consists of avoiding predisposing factors and initiating topical steroids and antifungal agents. [8] Surgical intervention is indicated only if medical treatment fails. See the image below.

Paronychia incision and drainage. Paronychia incision and drainage.

Felon

If frank abscess formation is present or the finger pad is tense, incision and drainage is indicated. This should not be undertaken lightly because improper placement of the incision can lead to scarring, sensory loss, unnecessary pain, instability of the finger pad, and spread of infection into the adjacent tendon sheath.

A longitudinal incision over the area of greatest fluctuance is the safest procedure when incision and drainage is required. Many other procedures, including hockey-stick or fish-mouth shaped incisions, are no longer recommended because of injury to neurovascular structure.

To avoid penetration of the tendon sheath, the incision should not extend to the distal interphalangeal crease. Using a hemostat, bluntly dissect the wound to promote drainage. Irrigate the cavity copiously and loosely pack with a gauze wick. After irrigation and loose packing of the wound, apply a dry gauze dressing and overlying splint. Update tetanus booster status as needed.

Herpetic whitlow

Apply a dry gauze dressing to the affected finger to prevent further spread of the lesion. Avoid incision or drainage of vesicles, which may lead to viremia and increase the risk for secondary bacterial infection. If secondary bacterial infection is suspected, treat appropriately with antibiotic therapy. [9] Antiviral agents, such as acyclovir, may shorten duration of symptoms if started within 48 hours of onset. [9, 10]

Infectious tenosynovitis and/or deep fascial space infections

ED care consists of making the correct diagnosis, providing pain relief, initiating antibiotic therapy, elevating and immobilizing the hand, and consulting an experienced hand surgeon promptly for definitive treatment. Experienced surgeons in the operating room should perform the incision and drainage.

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Consultations

Prompt consultation with an experienced hand surgeon is indicated for patients with evidence of infectious tenosynovitis, deep fascial space infections, or osteomyelitis.

Cases of chronic paronychia that do not respond to initial therapy should be referred to a dermatologist.

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Prevention

All care should be taken to avoid manicures or other salon procedures with unclean implements. Proper hand hygiene should be observed. [11]

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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Long-Term Monitoring

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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