Acute Paronychia with Suspected Abscess Formation
This patient has acute paronychia with probable abscess formation requiring immediate incision and drainage, combined with topical povidone iodine 2% twice daily and warm soaks. 1, 2
Clinical Diagnosis
The presentation is classic for acute paronychia progressing to abscess:
- Erythema and swelling surrounding the nail fold following hangnail trauma (breach of protective nail barrier) 2
- Pulsating, throbbing pain is pathognomonic for abscess formation 3
- "Airy" feeling on palpation without crepitus indicates fluid collection (pus) rather than gas 3
- 3cm difference in digit thickness confirms significant inflammatory response with likely purulent collection 2
The timeline (3 days from trauma to presentation) and symptom progression align with acute bacterial paronychia, most commonly caused by polymicrobial infection after the protective nail barrier was breached by hangnail manipulation 2.
Immediate Management Algorithm
Step 1: Determine Need for Drainage
Drainage is mandatory and the most important intervention when abscess is present 1. This patient's pulsating pain and "airy" palpation indicate established abscess requiring drainage 3.
Step 2: Perform Incision and Drainage
Multiple drainage techniques exist ranging from hypodermic needle instrumentation to wide scalpel incision, depending on abscess size and location 2. Given the significant swelling (3cm difference), adequate drainage is essential 3.
Step 3: Initiate Topical Therapy
- Apply topical povidone iodine 2% twice daily to the affected area 1, 4
- Warm water or dilute vinegar soaks (10-15 minutes twice daily) 1, 2
- Mid to high potency topical steroid ointment to nail folds twice daily to reduce inflammation 1
Step 4: Consider Systemic Antibiotics
Oral antibiotics are usually not needed if adequate drainage is achieved unless the patient is immunocompromised or severe infection is present 2. However, given the significant swelling and 3-day progression, consider oral antibiotics targeting most likely pathogens (Staphylococcus aureus, Streptococcus species) based on local resistance patterns 2.
Critical Pitfalls to Avoid
- Do not rely on antibiotics alone without drainage when abscess is present—this is the most common error and leads to treatment failure 1, 2
- Do not assume fungal infection in acute presentations; acute paronychia is typically bacterial, while Candida causes chronic paronychia (≥6 weeks duration) 1, 2
- Ensure tetanus prophylaxis is current for at-risk infections 3
Post-Drainage Care
- Splinting and elevation of the affected hand to reduce swelling 3
- Continue warm soaks with or without Burow solution or 1% acetic acid 2
- Patient education about avoiding nail trauma, not cutting nails too short, and proper nail care to prevent recurrence 1, 2
Follow-Up Considerations
Monitor for complications including: