1. Paronychia
Presentation
The patient will come with finger or toe pain that is either chronic and recurrent in
nature or has developed rapidly over the past several hours, accompanied by redness
and swelling of the nail fold. There are three distinct varieties:
• The chronic paronychia is most commonly seen with the "ingrown toenail" with
chronic inflammation, thickening and purulence of the eponychial fold and loss of
the cuticle. There may or may not be granulation tissue. This also occurs with
individuals whose hands are frequently exposed to moisture and minor trauma.
• The acute paronychia almost always involves fingers and is much more painful.
It is caused by the introduction of pyogenic bacteria by minor trauma and results
in acute inflammation and abscess formation within the thin subcutaneous layer
between the skin of the eponychial fold and the germinal layer of the eponychial
cul- de-sac. In its earliest subacute form there may only be cellulitis with no
collection of pus.
• The third variety of paronychia is a subungual abscess, which occurs in the same
location as a subungual hematoma, between the nail plate and the nail bed.
What to do:
• Perform a unilateral or bilateral digital block and establish a bloodless field with a
rubber tourniquet if a significant surgical procedure is anticipated.
• With a chronic paronychia:
o You may consider conservative treatment or temporizing the condition by
sliding a cotton wedge under the corner of an ingrown nail and placing
the patient on antibiotics (e.g., cefadroxil (Duricef) 500mg bid) and warm
soaks. Because of the slow growth of nails, this wedging may need to be
repeated for weeks or months. When candidiasis is suspected, the area
should be kept dry and treated with local applications of nystatin or other
topical antifungals. A long course of systemic medication may be required.
Followup with a podiatrist is important.
o A more aggressive approach, and one more likely to be successful, is to
sharply excise the entire wedge of affected nail, nailbed and lateral skin
fold down to the periosteum of the distal phalynx. Instruct the patient to
soak the toe in warm water for 20 min bid and arrange for multiple
followup visits. Extensive paronychia requires excision of the entire nail.
o Instruct the patient to cut toenails straight across to prevent any ingrown
nails
• With an acute paronychia:
o When there is minimal swelling and there appears to be only cellulitis,
gently use an 18 gauge needle to separate the cuticle of the lateral nail
fold to rule out or drain any collection of pus. Instruct the patient to soak
the finger in warm water for ten minutes qid and consider prescribing
antibiotics for three or four days.

2. o When there is redness and swelling of the nail fold, take an 18 gauge
needle or # 15 scalpel blade, separate the cuticle from the nail, open the
eponychial cul-de-sac and drain any abscess. Keep the needle or scalpel
tip flat against the dorsal surface of the nail. There is no need to make an
incision through the skin and thus a digital block is usually not necessary.
A tiny wick (1 cm of 1/4" gauze) may be slid into the opening to ensure
continued drainage. Debride any periungual pustules. Instruct the patient
in warm soaks at least qid. When drainage is complete, antibiotics are not
routinely required, but where significant cellulitis was present, a short
course of antibiotics may be indicated. Clindamycin (Cleocin) 150mg qid
or amoxicillin plus clavulanate (Augmentin) 250mg tid have a wide
spectrum of activity against most pathogens isolated from paronychia.
The patient should be informed that if the paronychia quickly recurs,
excision of a portion of the nail might be required.
o A more aggressive approach for tha more extensive infection is to excise a
portion of the nail. Unlike the more aggressive procedure used with the
chronic paronychia, only a portion of the nail need be removed, and no
underlying tissue. After establishing a digital block and a bloodless field,
simply insert a fine straight hemostat between the nail and the nail bed,
along the edge adjacent to the paronychia, and push and spread until you
enter the eponychial cul-de-sac. Often it is at this point that pus is
discovered. Then using a pair of fine scissors, cut away the quarter or
third of the nail bordering the paronychia. Separate the cuticle using the
hemostat and pull this unwanted fragment of nail away. A non-adherent
dressing is required over the exposed nailbed as well as an early dressing
change (within 24 hours).
• With a subungual abscess:
o You may consider conservative treatment not requiring a digital block.
Merely perform a trephination using the same "hot paper clip" technique
used for a subungual hematoma. The patient must provide frequent warm
soapy soaks over the next 36 hours to prevent recurrence.
o The more effective but more aggressive technique used when there is a
proximal collection of pus requires removal of the proximal 1/3 of the the
nail. A straight hemostat is required to separate the cuticle of the
eponychium from the underlying nail. Using the hemostat, the proximal
portion of the nail is pulled out from under the eponychium and excised.
On occasion an incision will have to be made along the lateral border of
the eponychium to allow the proximal nail to be excised. The removal of
the proximal portion of the nail allows for the complete drainage of the
abscess without any risk of recurrence. A non-adherent dressing is also
required in this instance. Extensive damage to the germinal matrix by the
infection may preclude healthy nail regrowth.
o When there is a distal collection of pus, a simple excision of an overlying
wedge of nail using iris scissors should provide complete drainage.
What not to do:

3. • Do not order cultures or x rays on uncomplicated cases.
• Do not make an actual skin incision. The cuticle only needs to be separated from
the nail in order to release any collection of pus.
• Do not remove an entire fingernail or toenail to drain a simple paronychia.
• Do not confuse a felon (tense tender finger pad) with a paronychia. Felons will
require more extensive surgical treatment.
Discussion:
Whenever conservative therapy is instituted, the patient should be advised as to the
advantages and disadvantages of that approach. If your patient is not willing or reliable
enough to perform the required aftercare or cannot accept the potential treatment
failure, then it would seem prudent to begin with the more aggressive treatment
modes.
No single antibiotic will provide complete coverage for the array of bacterial and fungal
pathogens cultured from paronychias. Theoretically, clincamycin or amoxicilln plus
clavulanate should be the most appropriate antibiotics, but because the vast majority of
paronychias are easily cured with simple drainage, systemic antibiotics are usually not
indicated. In immunocompromised patients and those with peripheral vascular disease,
cultures and antibiotics are indeed warranted.
Remain alert to the possible complications of a neglected paronychia such as
osteomyelitis, septic tenosynovitis of the flexor tendon or a closed space infection of the
distal finger pad (felon). Recurrent infections may be due to a herpes simplex infection
(herpetic whitlow) or fungus (onchomycosis). Tumors like squamous cell carcinoma or
malignant melanoma, cysts, syphilitic chancres, warts or foreign body granulomas can
occasionally mimic a paronychia. Failure to cure a paronychia within four or five days
should prompt specialized culture techniques, biopsy or referral.