What is the procedure for incision and drainage of a paronychia (whitlow)?

Incision and Drainage of Paronychia (Whitlow)

For paronychia requiring surgical intervention, perform incision and drainage by carefully opening the abscess, excising the eponychium if needed, mobilizing the nail fold away from the nail plate, performing necrosectomy, and ensuring complete drainage—antibiotics are typically unnecessary after adequate drainage unless systemic signs of infection are present. 1

Procedural Technique

Step-by-Step Approach

• Make the incision as close as possible to the affected area to ensure adequate drainage while minimizing tissue damage 2
• Open the abscess completely and evacuate all purulent material—inadequate drainage is the most common cause of treatment failure, more so than antibiotic selection 3, 1
• Excise the eponychium (proximal nail fold) if it is significantly involved in the infection 4
• Mobilize the nail fold away from the nail plate to access deeper collections 4
• Perform necrosectomy of any devitalized tissue and irrigate the cavity thoroughly 4
• Do NOT routinely pack the wound—packing is costly, painful, and provides no proven benefit for healing time or recurrence rates 2, 5
• Cover with a dry sterile dressing instead of packing material 6

Important Technical Considerations

• Ensure complete evacuation of all purulent material and loculations, as incomplete drainage leads to recurrence rates as high as 41% 2
• Culture the pus if the patient has recurrent infections, fails to respond to treatment, or has risk factors for MRSA 1
• The procedure can typically be performed under local anesthesia in the outpatient setting for simple cases 2

Post-Procedure Management

Wound Care

• Apply moist dressings and perform finger baths in the first few days after drainage 4
• Allow healing by secondary intention—do not close the wound primarily after acute drainage 6
• Avoid wound packing—recent evidence shows no benefit and increased patient discomfort 5

Antibiotic Decision Algorithm

Antibiotics are NOT needed if: 1

• The abscess was adequately drained
• No systemic signs of infection (temperature <38°C, heart rate <90 bpm)
• Erythema extends <5 cm from the wound edge
• Patient is immunocompetent
• No incomplete drainage or location concerns

Antibiotics ARE indicated if: 1

• Temperature >38°C or heart rate >90 bpm (SIRS criteria present)
• Erythema extends >5 cm beyond the abscess margins
• Patient is immunocompromised (diabetes, HIV/AIDS, immunosuppressive medications)
• Incomplete drainage or difficult-to-drain location
• Signs of systemic inflammatory response or organ dysfunction

Antibiotic Selection (When Indicated)

First-line oral options for MRSA coverage: 1

• Trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily
• Doxycycline 100 mg twice daily
• Clindamycin 300-450 mg three times daily

Duration: 5-10 days, adjusted based on clinical response 1

Common Pitfalls to Avoid

• Inadequate drainage is the primary cause of treatment failure—ensure complete evacuation of all purulent material 3, 1
• Unnecessary antibiotics—simple paronychia that has been adequately drained does not require antibiotics in most cases 3, 1
• Using wound packing routinely—this adds pain and cost without proven benefit 2, 5
• Failing to reassess within 48-72 hours—if no clinical improvement occurs, this may indicate inadequate drainage, resistant organisms, or deeper infection requiring further intervention 1
• Not recognizing systemic infection—do not confuse herpetic whitlow (viral) with bacterial paronychia, as herpetic infections should NOT be incised 4, 7