Background:

Paronychia is an infection around the nail edge, commonly arises after a manicure procedure or when biting ones nails. It is the most typical hand infection which can easily become chronic. The acute form is usually caused by S. Aures and the chronic form is usually caused by a fungal infection.

Typical appearance of paronychia.

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).


 

Examination and investigation:

Redness, tenderness and abscess formation around the nail edge are usually present in the acute form of paronychia.. In case of chronic paronychia, there’s only redness and tenderness without fluctuance. Other characteristics in the chronic form is nail thickening, discoloration and pronounced nail ridges.

 

Differential diagnosis:

Malignant melanoma (amelanotic melanoma) squamous cell carcinoma. Herpetic whitlow (must be distinguished from one another since the treatment is drastically different).

 

Treatment and Management:

The treatment depends on the extent of the infection. If diagnosed early, warm soaks 3-4 times/daily may resolve the infection. However if an abscess has developed, partial or total drainage must be performed. Surgical debridement can also be carried out but antibiotics are not usually necessary. Unless it’s a patient with diabetes, extensive cellulitis, peripheral vascular disease or is immunocompromised. A gram-positive coverage antibiotics must be used against S Aureus. E.g. amoxicillin, clavulanic acid, clindamycin or cephalexin. This should be prescribed along with the warm water soaks. 

This condition can be managed by the emergency physician or primary care doctor.

 

Consultation:

Surgical consultant is recommended in case of deep space infection, mucous cyst, osteomyelitis, glomus tumor or cellulitis.

 

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.

Paronychial erythema and edema with associated pustule. This suggests a bacterial etiology.

After simple drainage, there is purulent return.


 

Wound opened with a small incision using a number-11 blade scalpel.

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.

Differential diagnosis; this is herpetic whitlow


 

 

 

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