Surgical - Paronychia
Acute paronychia with abscess adjacent to the nail sulcus
Contraindications (absolute in bold)
Suspected underlying nail bed injury or fracture of the phalanx
Herpetic whitlow (localised abscess caused by herpes simplex)
Daily soaking in antiseptic solution (e.g. chlorhexidine) and topical antibiotics (e.g. mupirocin 2%)
Treatment with oral antibiotics (e.g. flucloxacillin 500mg orally four times a day for five days)
Less complex non-emergency procedure with low risk of complications
Failure (of drainage)
Bleeding and haematoma formation
Skin incision (with skin bridge necrosis)
Nail plate injury
Aseptic non-touch technique
PPE: non-sterile gloves, aprons, protective eyewear
Procedure room, private bed or chair space
Normal saline for irrigation
Sitting or lying with affected hand or foot placed on a flat and firm surface
5ml lignocaine 1-2% without adrenaline (for ring block, if used)
Consider performing a ring block of the relevant digit for large collections (see discussion)
Insert a scalpel blade along the nail under the nail fold until the pus escapes (abscess decompressed)
Lift the eponychium (skin fold) away from the nail with the blunt edge of the scalpel (nil skin incision required)
Use a non-adherent dressing to cover the incision site
Soaking affected digit in warm water four times a day
Apply a dry absorbent dressing after 48 hours
No follow-up required if resolution of redness, swelling, pain and discharge
Blanching of the skin on application of pressure to the distal volar aspect of the finger indicates an abscess
Consult the local hand specialist for complex abscess extending under the nail bed
MRSA is frequently cultured from these collections, as are anaerobes (likely from oral flora)
Herpetic whitlow is self-limited and should not be incised, as that may spread herpes simplex infection
A paronychia is an infection of the tissue around the nail root (known as the perionychium). Incision and drainage of a paronychia is required when the infection has progressed to an abscess adjacent to the nail.
Incision and drainage of paronychia with simple abscess adjacent to the nail does not require a skin incision (only lifting of the eponychial fold) and drainage often occurs with minimal insertion of the scalpel blade. The insertion is often not painful. In consult with the patient, the clinician may choose to perform a ring block prior to the procedure, however the ring block may be more painful than the procedure itself.
A discrete abscess away from the nail sulcus, will require incision and drainage as a normal cutaneous abscess with local anaesthetic (see separate procedure guide). An abscess under the nail (subungual) will require trephination or a partial or complete nail removal. For extensive paronychia with abscess, we recommend discussion with your local hand or orthopaedic specialist.
There is no evidence to suggest benefit of use of oral antibiotics in addition to surgical drainage for paronychia with abscess, however the use of oral antibiotics will depend on extent of infection and clinical judgement (e.g. extensive cellulitis or a patient with immunosuppression or diabetes may warrant antibiotics).
This guideline has been reviewed and approved by the following expert groups:
Emergency Care Institute
Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.
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