What is the treatment for a patient with inflammation and drainage of the lateral nail fold, as well as edema extending to the proximal interphalangeal (PIP) joint of the left long finger?

Treatment of Acute Paronychia with Proximal Extension

This patient requires urgent incision and drainage of the lateral nail fold abscess, combined with systemic antibiotics targeting Staphylococcus aureus and Streptococcus species, given the presence of purulent drainage and edema extending to the proximal interphalangeal joint. 1

Immediate Surgical Management

• Incision and drainage is the primary and essential treatment for this acute paronychia with purulent drainage 1, 2
• The procedure should use an intra-sulcal approach (along the nail fold) rather than a nail fold incision to optimize drainage 3
• Drainage must be performed urgently when an abscess is present, as antibiotics alone are ineffective for established purulent collections 2, 3
• Local anesthesia is typically sufficient for the procedure, with consideration for systemic analgesia if needed 2

Antibiotic Therapy Indications

Systemic antibiotics are mandatory in this case because the infection extends beyond the immediate nail fold to the PIP joint level, indicating deeper soft tissue involvement 1

Specific antibiotic recommendations:

• For outpatient management: Use oral agents active against Staphylococcus aureus and Streptococcus species 1

  • Options include cephalexin, dicloxacillin, or clindamycin 1
  • If MRSA risk factors are present (recent hospitalization, healthcare exposure, previous MRSA infection, injection drug use), use agents covering community-acquired MRSA such as trimethoprim-sulfamethoxazole, doxycycline, or clindamycin 1

• For severe cases requiring hospitalization: Intravenous vancomycin or a penicillinase-resistant penicillin (nafcillin) should be initiated 1

• Duration: Continue antibiotics for 5 days minimum, extending treatment if clinical improvement is inadequate 1

Critical Clinical Distinctions

The extension of edema to the PIP joint is the key factor mandating systemic antibiotics 1. This distinguishes the case from simple superficial paronychia, which can often be managed with drainage alone 1, 2.

Important pitfalls to avoid:

• Do not treat with antibiotics alone without drainage - this approach fails when purulent material is present 2, 3
• Do not assume fungal etiology - acute paronychia with purulent drainage is predominantly bacterial (Staphylococcus aureus or Streptococcus) 4, 3
• Do not perform nail avulsion unless there is an associated ingrown toenail; simple paronychia does not require nail removal 3

Post-Procedure Management

• Warm soaks 3-4 times daily to promote continued drainage 2
• Wound packing or wick placement may be necessary to maintain drainage 2
• Elevation of the affected hand to reduce edema 1
• Close follow-up within 24-48 hours to assess response to treatment 2

When to Escalate Care

Immediate surgical consultation is required if 1:

• Signs of deep space infection or flexor tenosynovitis develop
• Systemic signs of sepsis appear (fever, hypotension, altered mental status)
• No improvement occurs within 48 hours despite appropriate drainage and antibiotics

Blood cultures should be obtained if systemic inflammatory response criteria are present or the patient appears systemically ill 1