Diagnosis: Paronychia
This is acute paronychia—an infection of the nail fold that occurs after trauma to the protective nail barrier, such as pulling skin around the nail. The clinical presentation of a swollen finger following manipulation of the periungual skin with an intact nail bed is classic for this diagnosis 1.
Why This is Paronychia and Not the Other Options
- Felon involves infection of the pulp space of the fingertip (the fleshy pad), not the nail fold, and would present with tense swelling of the entire fingertip 2
- Onychomycosis is a chronic fungal infection requiring weeks to months to develop, presenting with nail thickening, discoloration, and friable texture—not acute swelling after recent trauma 3, 4
- Cellulitis would show spreading erythema and warmth extending beyond the immediate nail fold area into the finger or hand 2
Treatment Algorithm for Acute Paronychia
Initial Conservative Management (No Abscess Present)
Start with warm soaks and topical therapy as first-line treatment 1:
- Warm water soaks for 10-15 minutes, 2-3 times daily 3, 1
- Dilute vinegar soaks (50:50 dilution with water) twice daily can be used alternatively 3
- Mid-to-high potency topical corticosteroid ointment applied to nail folds twice daily to reduce inflammation 3, 1
- Topical antibiotics may be added with or without topical steroids when simple soaks don't relieve inflammation 1
If Abscess is Present
Drainage is mandatory when an abscess has formed 1, 2:
- Drainage options range from instrumentation with a hypodermic needle to incision with a scalpel 1
- Culture purulent material if present to guide antibiotic therapy 3
- Oral antibiotics are usually not needed if adequate drainage is achieved, unless the patient is immunocompromised or severe infection is present 1
Oral Antibiotic Indications
Oral antibiotics should target the most likely pathogens (typically Staphylococcus aureus and Streptococcus species) based on local resistance patterns 1:
- Required if: inadequate drainage, immunocompromised patient, or severe/spreading infection 1
- Consider doxycycline 100 mg twice daily for recurrent, severe, or treatment-refractory cases, with follow-up after 1 month 3
Special Consideration for This Patient (Hairdresser)
Occupational exposure is a critical factor 5:
- Hairdressers have chronic moisture exposure and chemical contact, which can lead to chronic paronychia if the acute episode doesn't fully resolve 3, 5
- Patient education is paramount to prevent recurrence: avoid excessive moisture, wear protective gloves when working with chemicals, and apply daily topical emollients to cuticles and periungual tissues 5, 1
Common Pitfall to Avoid
Do not confuse acute paronychia with herpetic whitlow, which can mimic an abscess but requires non-operative treatment 2. Herpetic whitlow typically presents with grouped vesicles and severe pain out of proportion to physical findings, and surgical drainage can lead to serious complications 2.