Surgical - Paronychia

Indications

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)

Alternatives

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)

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (of drainage)

Bleeding and haematoma formation

Skin incision (with skin bridge necrosis)

Nail plate injury

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: non-sterile gloves, aprons, protective eyewear

Area

Procedure room, private bed or chair space

Staff

Procedural clinician

Equipment

Scalpel

Normal saline for irrigation

Non-adherent dressing

Positioning

Sitting or lying with affected hand or foot placed on a flat and firm surface

Medication

5ml lignocaine 1-2% without adrenaline (for ring block, if used)

Sequence

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

Post-procedure care

Patient advice:

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

Tips

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

Discussion

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).

Peer review

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.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Goldstein BG, Goldstein AO, Tosti A. Paronychia. In: UpToDate. Waltham (MA): UpToDate. 2019 Jul 29. Retrieved Apr 2019. Available from: https://www.uptodate.com/contents/paronychia

eTG complete. Melbourne: Therapeutic Guidelines; 2015 Nov (updated 2019 Jun). Acute paronychia. Available from: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Dermatology&topicfile=nail-disorders&guidelineName=Dermatology&sectionId=toc_d1e379#toc_d1e379

Shafritz AB, Coppage JM. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014;22(3):165-174. doi:10.5435/JAAOS-22-03-165

Buttaravoli P, Leffler SM, editors. Minor emergencies. 3rd ed. Philadelphia PA: Saunders; p. 591-596.

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