Is it advisable to proceed with permanent toenail removal and treat the gluteal cyst with antibiotics (e.g. cephalexin) without drainage?

From the Guidelines

I would not recommend proceeding with permanent toenail removal while simultaneously treating a gluteal cyst with antibiotics alone, as this approach may increase the risk of infection and complicate recovery. The patient's chronic onychomycosis on the left big toenail can be addressed separately, and permanent removal (matricectomy) is typically reserved for recurrent cases after conservative measures have failed 1.

For the gluteal cyst, if infected (pilonidal cyst or abscess), drainage along with antibiotics is generally required for effective treatment 1. Cephalexin (500mg four times daily for 7-10 days) may help with surrounding cellulitis, but antibiotics alone are usually insufficient for an abscess or infected cyst, as the pus collection creates a protected environment where antibiotics cannot effectively penetrate.

Proper treatment typically involves incision and drainage of the cyst, followed by packing or wound care, along with antibiotics to address any surrounding infection 1. The most recent and highest quality study recommends that incisional SSIs should always be drained, irrigated, and if needed, opened and debrided 1.

Some key points to consider in the management of these conditions include:

• The importance of addressing each condition separately to minimize the risk of infection and complications
• The need for drainage and antibiotics in the treatment of infected gluteal cysts
• The role of conservative measures in the management of onychomycosis before considering permanent toenail removal
• The importance of evaluating each patient individually to determine the best approach for their specific condition 1.

From the FDA Drug Label

PRECAUTIONS General Indicated surgical procedures should be performed in conjunction with antibiotic therapy The FDA drug label does not directly answer whether it is advisable to proceed with permanent toenail removal and treat the gluteal cyst with antibiotics without drainage. However, it does mention that indicated surgical procedures should be performed in conjunction with antibiotic therapy. Given this information, it is unclear if treating the gluteal cyst with antibiotics without drainage is advisable. Proceeding with the permanent toenail removal may be done, but the decision to treat the gluteal cyst with antibiotics without drainage should be made with caution and careful consideration of the patient's overall condition 2.

• The patient's preference for antibiotic treatment instead of drainage should be taken into account.
• The potential risks and benefits of each approach should be weighed.
• It is essential to monitor the patient closely for any signs of complications or worsening of the condition.

From the Research

Onychomycosis Treatment

• Onychomycosis is a common fungal infection of the nail, causing discoloration and thickening of the affected nail plate 3.
• The diagnosis can be confirmed by direct microscopic examination with a potassium hydroxide wet-mount preparation, histopathologic examination of the trimmed affected nail plate with a periodic-acid-Schiff stain, fungal culture, or polymerase chain reaction assays 4.
• Treatment options include oral antifungals, topicals, and devices, with oral antifungals having higher cure rates and shorter treatment periods than topical treatments, but also having adverse side effects such as hepatotoxicity and drug interactions 3.

Permanent Toenail Removal

• Permanent toenail removal, also known as nail avulsion, is a surgical procedure that involves removing the entire nail plate 5.
• This procedure can be used to treat onychomycosis, especially in cases where the infection is severe or has not responded to other treatments 6.
• However, a study found that surgical nail avulsion with topical antifungal agents was not a very encouraging modality for the treatment of onychomycosis, with a high dropout rate and poor patient compliance 5.

Gluteal Cyst Treatment

• There is no direct evidence in the provided studies regarding the treatment of gluteal cysts with antibiotics.
• However, it is generally recommended to drain gluteal cysts, especially if they are infected, to prevent further complications and promote healing.

Proceeding with Permanent Toenail Removal and Treating Gluteal Cyst with Antibiotics

• Based on the provided evidence, it is not clear if proceeding with permanent toenail removal and treating the gluteal cyst with antibiotics (e.g. cephalexin) without drainage is advisable 7, 4, 3, 6, 5.
• The decision to proceed with this treatment plan should be made on a case-by-case basis, taking into account the patient's overall health, the severity of the onychomycosis and gluteal cyst, and the potential risks and benefits of each treatment option.