How to drain an abscess, such as one associated with paronychia?

Drainage of Abscesses, Including Paronychia

For a simple abscess such as paronychia, incision and drainage is the primary treatment, and antibiotics are typically not needed unless there are systemic signs of infection or significant surrounding cellulitis. 1

Paronychia Drainage Technique

• For acute paronychia with abscess formation, surgical drainage is the definitive treatment 2, 3
• Simple technique for paronychia drainage:
  • Clean the area with antiseptic solution (chlorhexidine or povidone-iodine) 4
  • Use a 21G or 23G needle to lift the nail fold and drain the pus 4
  • Alternatively, make a small incision at the point of maximal fluctuance 2
  • Avoid aggressive cutting of the nail fold which can lead to permanent nail deformity 3
• Following drainage, warm soaks with or without Burow solution or 1% acetic acid help with continued drainage and pain relief 2
• Daily dilute vinegar soaks (50:50 dilution) to nail folds twice daily for 10-15 minutes can be beneficial 1

Post-Drainage Care

• Keep the area clean and dry after drainage 1
• If significant inflammation persists, mid to high potency topical steroid ointment can be applied to nail folds twice daily 1
• For cases with onychocryptosis (ingrown nail), consider dental floss insertion under the ingrown nail to separate the lateral nail edge from underlying tissue 1
• Avoid prolonged exposure to moisture which can worsen the condition 2

When to Consider Antibiotics

• Antibiotics are not needed for simple, well-drained abscesses 1
• Consider antibiotics if any of the following are present:
  • Systemic inflammatory response syndrome (SIRS): temperature >38°C or <36°C, tachypnea >24 breaths/minute, tachycardia >90 beats/minute, or white blood cell count >12,000 or <400 cells/µL 1
  • Immunocompromised patient 1
  • Significant surrounding cellulitis extending beyond the abscess borders 1
  • Incomplete source control (inadequate drainage) 1

Complex Abscess Management

• For complex abscesses (larger, deeper, or multiloculated):
  • More extensive surgical drainage may be required 1
  • Large abscesses should be drained with multiple counter incisions rather than a single long incision to prevent step-off deformity and delayed wound healing 1
  • For perianal/perirectal abscesses, the incision should be kept as close as possible to the anal verge to minimize potential fistula length 1
  • The timing of surgery depends on the patient's clinical condition - emergent drainage is needed for sepsis, immunosuppression, diabetes mellitus, or diffuse cellulitis 1

Special Considerations

• For recurrent paronychia, evaluate for underlying causes:
  • Chemical irritants (common in housekeepers, dishwashers, bartenders) 2
  • Chronic moisture exposure 2
  • Systemic conditions that may predispose to infection 3
• For chronic paronychia (symptoms >6 weeks), treatment focuses on:
  • Eliminating the source of irritation 2
  • Topical steroids or calcineurin inhibitors for inflammation 2
  • Dermatology consultation for resistant cases 5

Common Pitfalls to Avoid

• Inadequate drainage is associated with high recurrence rates (up to 44% in some cases) 1
• Probing for fistulas in simple abscesses is not recommended and may cause additional tissue damage 1
• Avoid aggressive cutting of the nail fold in paronychia, which can lead to permanent nail deformity 3
• Don't rely solely on antibiotics without proper drainage for abscess treatment 1
• Be vigilant for unusual or resistant cases which may indicate underlying conditions requiring further investigation 5