Paronychia

 

  • Infection in the skin fold (or paronychium) to lateral edge of the nail (of the finger or toe, but most commonly finger).
  • Leads to a pus filled abscess.
  • Can result in cellulitis of the digit, and any other complications usually seen with this.
  • Is often very painful.
  • Common in nail biting.

  • There is poor evidence for the use of antibiotics in the absence of cellulitis or other predisposing factors (such as the immune suppressed)
  • Drainage of the abscess is standard treatment. Seems to be effective in the absence of antibiotics.
  • Antibiotics rarely effective on their own.
  • However, there is little research into the treatment of this condition.

 

Treatment

 

Incision and drainage of the paronychia is standard and appears to be effective.

There are a number of ways to undertake this, here are a few.

  • Use of ethyl chloride to provide some analgesic cover and incision over the abscess.
    • In my experience this works well with large well formed abscess where you can incise over the collection well. It’s quick and more or less pain free in this case.
    • Not useful where there is a small, low lying or not visible collection where it can be painful for the patient.
  • Use of ring blocking the digit and either incision as above or incision under the skin fold (between the nail and skin).
    • This is useful in the above cases and some of my colleagues prefer this method in all cases.

 

 

 

 

  • Soaking of the digit (in warm water for +10mins) and use of a thin blunt instrument to separate the skin fold from nail. This is a new technique to me but seems worth considering.
    • This is apparently painless.
    • The aim is to gently separate the skin fold from the nail rather than incising this.
    • You can “teach” the patient how to repeat the procedure if the abscess begins to refill.

 

You can see above the use of a needle to “lift” the nail fold. Anything flat and relatively blunt (such a splinter forceps) is effective and from a psychological point of view maybe be better tolerated than use of a needle or scalpel.

 

  • Then dress with an antibacterial dressing (such as iodine gauze) and tell the patient not to elevate the finger to encourage drainage.
  • Decide whether to prescribe antibiotics (yes, in the case of any progressive cellulitis or those immunocompromised).
  • Good safety netting as with any infection.
  • Review if symptoms recurrent or not settled (I usually say in three days).

Further reading

I strongly recommend going to have a look at this excellent post on ST.EMLYN’S which was my inspiration for writing this, and discusses A&P, treatment, differentials and some complications in more detail.

 

 

 

 

2 comments

    • Diccon says:

      I tend to use this now as my go to technique and it seems to be very well tolerated by the patient.

      My preferred instrument for this is the back of scalpel as it is nice an fine and a good balance between rigid/flexing. But you have to be careful not to slide back again as then you are actually incising the finger.

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