Case 

A 34-year-old female presents to the emergency department with redness and pain to the nail of her right middle finger. She first noticed some redness a few days ago but didn't think much of it. Over the last few days, it has worsened and become more puffy and red. She is a dishwasher so is always using her hands and banging them on things. No discernable trauma she can recall. She denies any numbness, tingling, fever or chills. On exam, she is hemodynamically stable and neurovascularly intact in her right hand. On the lateral aspect of her right middle fingernail she has erythema, fluctuance and tenderness to touch. The distal tip of her finger appears normal. No herpetic lesions. Fingernail itself appears normal. 

Diagnosis  

Paronychia 

Discussion

A paronychia is inflammation of the skin around a finger or toenail, usually located along the lateral or proximal nail. The inflammation can be acute or chronic based on duration of symptoms with acute being defined as less than six weeks and chronic defined as greater than six weeks. The inflammation is most often caused by a bacterial infection, commonly staphylococcus aureus and streptococcus. Less commonly, the infection can be viral or fungal in origin. [1,2]

Patients with an acute paronychia typically present with pain, redness and, swelling along one nail fold. Abscess formation is common with paronychia and if present will be seen as fluctuance on exam. [1,2]

Treatment of acute paronychia without abscess includes antibiotics and symptomatic treatment with warm water soaks 2-3 times daily. Antibiotic choice is physician dependent as there is no strong evidence for topical versus oral antibiotics as long as they cover the common pathogens (staph and strep). Topical antibiotics used include bacitracin or mupirocin. Oral antibiotics include dicloxacillin or cephalexin. If a patient has MRSA risk factors, broader coverage is indicated. [1]

Treatment for paronychia with abscess is incision and drainage. The procedure is simple and can be done at bedside. [1,2]

Supplies to collect for paronychia drainage include:

• Alcohol prep pad

• 10 cc syringe

• 18 gauge needle to draw up lidocaine

• 27 gauge needle to administer lidocaine

• #11 blade scalpel and gauze.

The procedure:

1. Draw up lidocaine with a large bore needle into a 10 cc syringe.

2. Clean insertion site with alcohol pad.

3. Anesthetize locally or perform a digital block.

4. After adequately anesthetizing insert the 11 blade scalpel into the lateral nail fold until the pus drains. You can apply pressure proximal to the abscess to aid in drainage.

5. After drainage, patients should do warm soaks and follow with a provider in 24-48 hours to ensure the collection has not reaccumulated. Antibiotics are not indicated but if there is significant cellulitis or provider concern, similar regimens as above can be prescribed.  [1]

6. Prior to discharge, it is important to counsel patients on hand hygiene. This includes keeping their hands as clean and dry as possible especially until resolution of erythema and/or drainage. Any patients who frequently have wet hands for their work are encouraged to use gloves for all wet work. This prevents worsening bacterial infection of the nail. Additionally, patients are encouraged to keep their nails short and avoid any nail biting or cuticle cutting. [3] 

Case resolution

The paronychia was drained and the patient was instructed to do warm soaks and take oral antibiotics as she has her hands in water at her job. She was encouraged to wear gloves at all times during wet work and keep her hands as dry as possible. She followed up with her primary in two days and there was no recollection of the abscess. 

Takeaways

• Paronychia is a nail fold infection 

• Treatment without abscess includes warm soaks and topical vs. oral antibiotics 

• Treatment with abscess includes incision and drainage 

• Patients should be counseled on hand hygiene particularly keeping hands as clean and dry as possible. This means wearing gloves for anyone who does wet work. 

Author: Katie Miller, Brown Emergency Medicine PGY 4 at Brown Emergency Medicine

Faculty Reviewer: Kristina McAteer, MD is an attending physician at Rhode Island Hospital and Newport Hospital

ReferenceS

1. Dulski A, Edwards CW. Paronychia. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544307/

2. “Paronychia (Nail Infection): What Is It, Symptoms, Causes and Treatment.” Cleveland Clinic, 2022, https://my.clevelandclinic.org/health/diseases/15327-nail-infection-paronychia#:~:text=Paronychia%20is%20nail%20inflammation%20that,the%20base%20of%20the%20nail. 

3. Rigopoulos, D., Larios, G., Gregoriou, S., & Alevizos, A. (2008). Acute and chronic paronychia. American family physician, 77(3), 339–346.