Is partial nail avulsion indicated for a 22‑year‑old healthy male with a left ring‑finger paronychia that has failed treatment with amoxicillin, doxycycline, and amoxicillin again?

Partial Nail Avulsion for Antibiotic-Refractory Paronychia

Yes, partial nail avulsion is appropriate for this patient with paronychia that has failed multiple courses of oral antibiotics, but only after obtaining bacterial/viral/fungal cultures and attempting topical therapy first unless there is evidence of a subungual abscess requiring immediate drainage. 1

Immediate Assessment Required

Before proceeding to surgery, you must determine:

• Check for fluctuance or abscess formation – if present, this mandates immediate surgical drainage rather than continued conservative management 2, 1, 3
• Obtain bacterial, viral, and fungal cultures immediately before any intervention, as up to 25% of paronychia cases involve secondary bacterial or mycological superinfections that explain antibiotic failure 2, 1, 3
• Assess for signs of onychocryptosis (ingrown nail) – the nail plate may be piercing the perionychium, which would support the need for partial avulsion 2

Treatment Algorithm Based on Severity

If No Abscess Present (Grade 2 Paronychia)

Try topical therapy first for 2 weeks before proceeding to surgery:

• Apply 2% povidone-iodine twice daily combined with high-potency topical corticosteroids 2, 1, 3
• Implement antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 1, 3
• Reassess after 2 weeks – if no improvement or worsening, proceed to partial nail avulsion 2, 1, 3

If Abscess Present or Grade ≥3 (Intolerable Grade 2)

Proceed directly to partial nail avulsion:

• This is indicated for severe paronychia with painful lesions, subungual abscess, or failure of medical management after 2 weeks 2, 1
• The presence of pus mandates drainage regardless of prior antibiotic courses 4, 5

Surgical Technique Considerations

• Clean and culture the nail bed at the time of avulsion to guide any subsequent antimicrobial therapy 2
• Ensure complete drainage of any abscess, as inadequate excision is the primary cause of treatment failure 6
• The nail should be cut regularly until the nail plate grows reattached 2

Post-Operative Management

Antibiotics are NOT routinely needed after adequate surgical drainage in immunocompetent patients:

• A prospective study of 46 patients showed excellent outcomes (98% healing) with surgical excision alone, without postoperative antibiotics 6
• Reserve antibiotics for immunocompromised patients, diabetics, or if there are signs of spreading infection (lymphangitis, cellulitis) 6
• If cultures grow organisms, treat based on sensitivities rather than empirically 1

Common Pitfalls to Avoid

• Do not continue cycling through oral antibiotics indefinitely – this patient has already failed three courses, indicating either an abscess requiring drainage, a resistant organism, or a fungal/non-bacterial etiology 1, 4
• Do not perform partial avulsion without obtaining cultures – you need to know what organism is present to guide any subsequent therapy 2, 1
• Do not overlook fungal infection – Candida is present in up to 25% of cases and will not respond to antibacterial therapy 2, 1, 3
• Ensure complete excision – the single most important factor for success is adequate drainage; incomplete excision leads to recurrence 6

Prevention of Recurrence After Healing

• Trim nails straight across and not too short 2, 3
• Keep hands dry and wear protective gloves during water exposure 1, 3
• Apply emollients regularly to cuticles and periungual tissues 2, 3