Paronychia: Difference between revisions

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==Background==
==Background==
*Usually caused by minor trauma (e.g. nail-biting, manicures, hangnails)  
*Inflammation/infection of the proximal or lateral nail folds<ref name="Larios">Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008 Feb 1;77(3):339-46.</ref>
*Usually caused by direct or indirect minor trauma (e.g. nail-biting, manicures, hangnails, ingrown nail, dishwashing)
**Trauma allows entry of bacteria
**''S. aureus'' is most common, although ''S. pyogenes'', ''Pseudomonas pyocyanea'', and ''Proteus vulgaris'' are also common<ref name="Larios" />
 
[[File:Paronychia.jpg|thumbnail|Paronychia of middle digit]]


==Clinical Features==
==Clinical Features==
[[File:Paronychia.jpg|thumbnail|Paronychia of middle digit]]
*Rapid onset of erythema, edema, and pain of proximal or lateral nail folds<ref name="Larios" />
*Infection of lateral nail fold or perionychium
*Usually only affects one nail
*May see purulent drainage (expressed with pressure on nail)


==Differential Diagnosis==
==Differential Diagnosis==
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==Diagnosis==
==Diagnosis==
===Workup===
*Clinical diagnosis, based on history of minor trauma and physical examination
*May consider culturing pus drained
*If unclear if wound is fluctuant:
 
**Have pt apply pressure to distal aspect of affected digit
===Evaluation===
**A larger than expected area of blanching, reflecting a collection of pus, may identify need for drainage
*Usually a clinical diagnosis


==Treatment==
==Treatment==
===Acute===
===Acute===
*more likely bacterial
*More likely to be bacterial
*If no fluctuance is identified:
*If no fluctuance is identified:
**Warm soaks, elevation
**Warm compresses, soaks, elevation
**[[TMP-SMX DS]] 1-2 tab PO x 7-10d + ([[cephalexin]] 500mg PO QID x7-10d OR [[dicloxacillin]] 500mg PO QID x 7–10d)
**Antibiotic ointment TID x5-10 days (mild cases) ± topical steroid
*If unclear if wound is fluctuant:
**PO Antibiotics (more severe or persistent cases)<ref name="Larios" />
**Have pt apply pressure to distal aspect of affected digit
***Augmentin BID x7 days '''OR'''
**A larger than expected area of blanching, reflecting a collection of pus, may identify need for drainage
***Clindamycin 150-450mg TID or QID x7 days '''OR'''
*If fluctuance or pus is identified:
***[[TMP-SMX DS]] 1-2 tab PO BID x7 days
*If fluctuance or purulence is identified:
**Consider soaking hand for preparation
**Consider soaking hand for preparation
**Consider [[digital block]]
**Consider [[digital block]]
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***Incise parallel to nail (do NOT incise perpendicular to fluctulance)  
***Incise parallel to nail (do NOT incise perpendicular to fluctulance)  
***Use iris scissors, flat tweezers, or #11 blade
***Use iris scissors, flat tweezers, or #11 blade
***Insert small packing to allow for drainage


===Chronic===
===Chronic===
*more likely fungal
*Multifactorial inflammation due to persistent irritation - may also have fungal component<ref name="Larios" />
*Plain X-ray to rule out [[foreign body]] or [[osteo]]
*Mainstay of therapy is avoidance of irritant
*vinegar/bleach soaks
*Consider topical antifungals vs Diflucan 150mg po qweek x 4-6 weeks
*topical antifungals vs Diflucan 150mg po qweek x 4-6 weeks


==Disposition==
==Disposition==
*Wound check in 24-48hr
*Discharge


==See Also==
==See Also==
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==References==
==References==
<references/>


[[Category:ID]]
[[Category:ID]]
[[Category:Ortho]]
[[Category:Ortho]]

Revision as of 03:06, 10 September 2015

Background

  • Inflammation/infection of the proximal or lateral nail folds[1]
  • Usually caused by direct or indirect minor trauma (e.g. nail-biting, manicures, hangnails, ingrown nail, dishwashing)
    • Trauma allows entry of bacteria
    • S. aureus is most common, although S. pyogenes, Pseudomonas pyocyanea, and Proteus vulgaris are also common[1]
Paronychia of middle digit

Clinical Features

  • Rapid onset of erythema, edema, and pain of proximal or lateral nail folds[1]
  • Usually only affects one nail
  • May see purulent drainage (expressed with pressure on nail)

Differential Diagnosis

Hand and finger infections

Look-Alikes

Diagnosis

  • Clinical diagnosis, based on history of minor trauma and physical examination
  • If unclear if wound is fluctuant:
    • Have pt apply pressure to distal aspect of affected digit
    • A larger than expected area of blanching, reflecting a collection of pus, may identify need for drainage

Treatment

Acute

  • More likely to be bacterial
  • If no fluctuance is identified:
    • Warm compresses, soaks, elevation
    • Antibiotic ointment TID x5-10 days (mild cases) ± topical steroid
    • PO Antibiotics (more severe or persistent cases)[1]
      • Augmentin BID x7 days OR
      • Clindamycin 150-450mg TID or QID x7 days OR
      • TMP-SMX DS 1-2 tab PO BID x7 days
  • If fluctuance or purulence is identified:
    • Consider soaking hand for preparation
    • Consider digital block
    • Incise area of greatest fluctuance
      • Incise parallel to nail (do NOT incise perpendicular to fluctulance)
      • Use iris scissors, flat tweezers, or #11 blade

Chronic

  • Multifactorial inflammation due to persistent irritation - may also have fungal component[1]
  • Mainstay of therapy is avoidance of irritant
  • Consider topical antifungals vs Diflucan 150mg po qweek x 4-6 weeks

Disposition

  • Discharge

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008 Feb 1;77(3):339-46.
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