From the Guidelines
The patient with paronychia of the right great toe should be assessed and managed according to the severity of the condition, with gentle skin care, antimicrobial soaks, and topical or oral antibiotics as needed, as recommended by the most recent guidelines 1. The assessment of paronychia involves evaluating the severity of the condition, which can range from grade 0 to grade 3, according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 1.
- Grade 0 prevention involves gentle skin care instructions, wearing comfortable shoes, and avoiding biting nails or cutting nails too short, with a level of evidence (LoE) of IV and a grade of recommendation (GoR) of B 1.
- Grade 1 treatment involves continuing the current treatment and monitoring for changes in severity, with topical povidone iodine 2% and topical antibiotics/corticosteroids, with a LoE of III and a GoR of B 1.
- Grade 2 treatment involves continuing the current treatment and monitoring for changes in severity, with topical povidone iodine 2%/topical beta-blocking agents/topical antibiotics and corticosteroids and/or oral antibiotics, with a LoE of III and a GoR of B 1.
- Grade 3 treatment involves interrupting the current treatment until the condition improves to grade 0 or 1, with surgical intervention or antibiotics indicated, and a LoE of III and a GoR of B 1. The patient's history and physical exam should be taken into consideration when determining the severity of the condition and the appropriate treatment plan.
- The patient's symptoms, such as pain, redness, and swelling, should be evaluated, as well as any potential trauma or infection.
- The physical exam should include an assessment of the nail fold, looking for signs of erythema, edema, and tenderness, as well as any purulent discharge. The treatment plan should be tailored to the individual patient's needs, with consideration of the severity of the condition, the patient's medical history, and any potential allergies or interactions with other medications.
- The patient should be advised to keep the area clean and dry, and to elevate the foot when possible, to promote healing and prevent further complications.
- The patient should also be educated on proper nail care, including avoiding tight footwear and trauma to the nail folds, to prevent recurrence of the condition. Overall, the management of paronychia requires a comprehensive approach, taking into consideration the severity of the condition, the patient's medical history, and the potential for complications, with the goal of promoting healing, preventing further complications, and improving the patient's quality of life.
From the Research
Assessment of Paronychia
- The patient's presentation of paronychia of the right great toe should be assessed for signs of acute or chronic infection, including inflammation, abscess, or exposure to irritants 2, 3.
- A thorough medical history should be taken to determine the presence of any underlying conditions, such as immunocompromising diseases, that may affect treatment 2.
- The patient should be questioned about any recent trauma to the toe, as trauma is a major contributing factor to retronychia, a condition that may present with similar symptoms to paronychia 4, 5.
Treatment Plan
- For acute paronychia, treatment may include warm soaks with or without Burow solution or 1% acetic acid, topical antibiotics, and topical steroids 2, 3.
- If an abscess is present, drainage may be necessary, which can be achieved through instrumentation with a hypodermic needle or a wide incision with a scalpel 2.
- For chronic paronychia, treatment should focus on stopping the source of irritation and treating the inflammation with topical steroids or calcineurin inhibitors 2, 3.
- In cases where retronychia is suspected, avulsion of the nail plate may be necessary, as antibiotics and antifungals are often ineffective in these cases 4, 5.
- Patient education is crucial to reduce the recurrence of paronychia, including avoiding exposure to irritants and practicing nail care 2, 3.