Management of Finger Felons
The primary treatment for a felon is prompt surgical incision and drainage without the need for antibiotics in uncomplicated cases. 1
Diagnosis and Clinical Presentation
- A felon is an abscess in the pulp space of the fingertip that presents with pain, swelling, erythema, and induration 2
- As the abscess matures, fluctuance and purulent drainage may develop 3
- The infection can lead to digital compartment syndrome if not adequately drained 2
Treatment Algorithm
Primary Management
- Prompt surgical drainage is the essential first-line treatment for all felons with abscess formation 1, 2
- The preferred approach is a longitudinal incision in the volar space if superficial or lateral approach if deep, with careful attention not to extend past the distal interphalangeal joint 2
- Complete surgical excision is critical for successful treatment and to prevent recurrence 1
Antibiotic Considerations
- Antibiotics are NOT routinely indicated following surgical drainage of uncomplicated felons in immunocompetent patients 1
- A prospective study of 46 patients with felons and paronychia showed excellent healing (45/46 cases) with surgical drainage alone without antibiotics 1
When to Add Antibiotics
Antibiotics should be added to surgical drainage only when:
- Systemic signs of infection are present (temperature >38.5°C, heart rate >110 beats/minute) 3
- Erythema extends >5 cm from the wound edge 3
- Patient is immunocompromised 1
- Presence of lymphangitis or other complications (osteomyelitis, tenosynovitis, septic arthritis) 1, 4
Antibiotic Selection (When Indicated)
- First-line: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 5, 6
- For penicillin-allergic patients: Doxycycline 100 mg twice daily 5
- For severe infections requiring IV therapy: Ampicillin-sulbactam or piperacillin-tazobactam 5
- Consider MRSA coverage with vancomycin or linezolid in patients with prior MRSA history, treatment failure, or severe infection 3, 5
Post-Procedure Care
- Elevation of the extremity to reduce swelling 4
- Removal of constricting jewelry 4
- Dressing changes until the wound heals by secondary intention 7
- Follow-up within 24-48 hours to assess healing 1
Special Considerations
Complicated Infections
- Deep abscesses may have minimal local symptoms but significant systemic manifestations 3
- Failure to drain an abscess adequately can lead to persistent infection, regardless of antibiotic therapy 3
- Mycobacterium abscessus infections (rare) have been reported following nail salon visits and require prolonged combination antibiotic therapy 8
High-Risk Patients
- Patients with diabetes, immunosuppression, or prosthetic heart valves require more aggressive management including antibiotics even after surgical drainage 1
- These patients may require broader spectrum coverage and a lower threshold for IV therapy 5