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Clinical Summary

Paronychia is the most common hand infection and is characterized by inflammation and pus accumulation along a lateral nail fold. It may spread to involve the eponychium at the base of the nail and the opposite nail fold if untreated. S aureus is most frequently isolated, although the infection is generally mixed flora. Felon, dactylitis, herpetic whitlow, hydrofluoric acid burn, and traumatic injury should be considered in the differential.

Management and Disposition

If paronychia is recognized early, prior to frank abscess formation, warm soaks with or without oral antibiotics may be sufficient. After 2 to 3 days, there may be enough pus accumulation along the eponychial fold to warrant incision and drainage. After digital block, a #11 blade or 18-gauge needle is advanced parallel to the nail and under the eponychium at the site of maximal fluctuance. If pus has collected under the nail (subungual abscess), then a portion must be removed to provide drainage. Oral antibiotics should be prescribed; the patient should be reevaluated in 2 to 3 days.

FIGURE 12.35

Paronychia. A paronychia involving one lateral fold and the eponychium. There is swelling, erythema, and tenderness on the dorsum of the distal phalanx. (Photo contributor: Frank Birinyi, MD.)

Pearls

  1. Paronychia is associated with nail biting, manicure trauma, and foreign bodies.

  2. Germinal matrix damage during nail plate excision may result in nail deformity.

  3. It is important to distinguish a paronychia from herpetic whitlow, where incision and drainage is contraindicated.

FIGURE 12.36

Paronychia. A paronychia involving the medial fold and eponychium. (Photo contributor: Selim Suner, MD, MS.)

FIGURE 12.37

Paronychia. Incision and drainage of a paronychia with considerable purulent drainage. (Photo contributor: Selim Suner, MD, MS.)

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