What is the appropriate treatment for a patient with an ingrown toenail and purulent discharge?

From the Guidelines

The patient with an ingrown toenail and purulent discharge should be treated with a combination of conservative measures, including warm water soaks, oral antibiotics, and pain management, alongside a minor surgical procedure such as partial nail avulsion. The history of present illness (HPI) for this patient includes a 2-3 day history of painful swelling and purulent discharge involving her right great toe, with the pain described as constant and throbbing, localized to the medial aspect of the nail fold. Given the presence of pus, indicating an infection, treatment should prioritize addressing this infection. According to the provided evidence 1, for a patient presenting with pus, the recommendation is to culture and treat the infection, which aligns with the use of oral antibiotics. Key aspects of the treatment plan include:

• Oral antibiotics to address the infection, such as cephalexin or clindamycin, as indicated by the presence of purulent discharge.
• Pain management with acetaminophen or ibuprofen as needed.
• Consideration of a minor surgical procedure, such as partial nail avulsion, to remove the ingrown portion of the nail under local anesthesia.
• Post-procedure care including topical antibiotics and keeping the area clean and dry. This approach prioritizes reducing morbidity and mortality by addressing the infection promptly and effectively, while also improving the patient's quality of life by alleviating pain and preventing recurrence of the ingrown toenail.

From the Research

History of Present Illness (HPI)

• The patient is a 24-year-old female who presents with a 2-3 day history of painful swelling and purulent discharge involving her right great toe.
• She describes the pain as constant and throbbing, localized to the medial aspect of the nail fold, and reports that it has been progressively worsening since onset.
• The swelling appeared concurrently with the pain, and she first noticed purulent discharge yesterday morning.
• The patient's symptoms are consistent with an ingrown toenail, which has become infected, as evidenced by the presence of pus and increasing pain.

Treatment Options

• According to 2, treatment for acute paronychia, which is likely the diagnosis in this case, consists of warm soaks with or without Burow solution or 1% acetic acid.
• Topical antibiotics should be used with or without topical steroids when simple soaks do not relieve the inflammation.
• The presence of an abscess, which is likely given the purulent discharge, mandates drainage, which can be achieved through various methods, including instrumentation with a hypodermic needle or a wide incision with a scalpel.
• Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or a severe infection is present, as seen in the case report 3, where the patient developed extensive pyomyositis secondary to a paronychia-related MRSA infection.

Considerations

• It is essential to determine the presence of an abscess and to achieve adequate drainage to prevent further complications, such as pyomyositis, as reported in 3.
• The patient's treatment should be based on the most likely pathogens and local resistance patterns, as mentioned in 2.
• Patient education is crucial to reduce the recurrence of acute and chronic paronychia, as emphasized in 2.