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 compromise the patient's outcome. The patient's chronic onychomycosis can be addressed after the gluteal cyst infection is properly managed. For the gluteal cyst, particularly if it's infected (pilonidal cyst or abscess), antibiotics alone without drainage is often insufficient, as noted in the guidelines for the management of skin and soft tissue infections 1. An infected cyst generally requires incision and drainage, followed by antibiotics like cephalexin 500mg four times daily for 7-10 days to address residual infection.
The reason for this approach is that antibiotics cannot adequately penetrate the walled-off infected material within a cyst, making drainage necessary to remove the purulent material 1. Additionally, undergoing a toenail procedure while having an active infection elsewhere increases infection risk at the surgical site. The better approach would be to address the more urgent condition first (likely the infected cyst with drainage and antibiotics) and once resolved, consider appropriate management for the toenail issue.
Some key points to consider in the management of skin and soft tissue infections include:
- Incisional SSIs should always be drained, irrigated, and if needed, opened and debrided 1
- Superficial incisional SSIs that have been opened can usually be managed without antibiotics, but patients with systemic inflammatory response criteria or signs of organ failure may require empiric broad-spectrum antibiotic treatment 1
- The management of onychomycosis may involve surgical avulsion, topical antifungal therapy, or other treatments, but the evidence for these approaches is limited 1
In this case, the priority should be to manage the infected gluteal cyst with incision and drainage, followed by antibiotics, and then address the toenail issue once the infection is resolved. This approach is supported by the guidelines for the management of skin and soft tissue infections 1 and prioritizes the patient's morbidity, mortality, and quality of life.
From the FDA Drug Label
Indicated surgical procedures should be performed in conjunction with antibiotic therapy The FDA drug label does not answer the question.
From the Research
Onychomycosis Treatment
- Onychomycosis is a common fungal infection of the nail, causing discoloration and thickening of the affected nail plate 2.
- 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 3.
- 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 2.
Permanent Toenail Removal
- Permanent toenail removal, also known as nail avulsion, is a surgical procedure that involves removing the entire nail plate 4.
- This procedure can be used to treat onychomycosis, especially in cases where the infection is severe or has not responded to other treatments 5.
- 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 4.
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 6, 3, 2, 5, 4.
- 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.