What is the treatment plan for a 41-year-old male with diabetes and paronychia of the left great toenail?

From the Guidelines

The treatment plan for J.D. should prioritize managing his paronychia while considering his diabetes history, focusing on drainage, topical and oral antibiotics, pain management, and preventive measures to avoid recurrence and complications. Given the presence of drainage indicating infection, an oral antibiotic such as cephalexin 500mg four times daily for 7-10 days would be appropriate to treat the likely Staphylococcus or Streptococcus infection, as suggested by general principles of treating skin infections 1. For pain management, acetaminophen 650mg every 6 hours or ibuprofen 400mg every 6 hours as needed would be suitable, though ibuprofen should be used cautiously given his diabetes. J.D. should elevate the foot when possible and wear open-toed footwear to reduce pressure on the affected toe. Due to his diabetes, blood glucose monitoring should be more frequent during the infection period as infections can affect glycemic control, and he should be educated on proper foot care, including daily foot inspections, proper nail trimming techniques (cutting nails straight across and not too short), and the use of emollients to moisturize dry skin, as recommended by guidelines for preventing foot ulcers in diabetic patients 1. If no improvement occurs within 48-72 hours of antibiotic therapy, or if symptoms worsen, he should return for reevaluation as surgical drainage might be necessary. Proper nail trimming techniques and footwear advice should be discussed to prevent recurrence, considering the patient's diabetes status and the risk of foot complications. The most recent guidelines on the prevention of foot ulcers in persons with diabetes emphasize the importance of regular foot examinations, proper foot care, and the use of appropriate footwear to prevent complications 1. In the context of paronychia, drainage is a critical intervention, alongside topical and oral antibiotics, to manage the infection effectively and prevent further complications, especially in a diabetic patient who is at higher risk of infection-related morbidity and mortality 1.

From the FDA Drug Label

PRECAUTIONS General Prescribing cephalexin capsules, cephalexin for oral suspension, or cephalexin tablets in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria The patient has a proven bacterial infection as indicated by the symptoms of redness, swelling, throbbing pain, and mild yellow drainage.

• The treatment plan would be to prescribe cephalexin as it is effective against bacterial infections.
• The patient should be closely monitored for any side effects or unusual manifestations of drug idiosyncrasy.
• It is essential to complete the full course of therapy to decrease the effectiveness of the immediate treatment and increase the likelihood that bacteria will develop resistance. 2 2

From the Research

Treatment Plan for J.D.

Given J.D.'s symptoms of redness, swelling, and throbbing pain at the left great toenail, which began after trimming the nail too short, the likely diagnosis is acute paronychia. The treatment plan for J.D. should be based on the following:

• Warm soaks with or without Burow solution or 1% acetic acid to relieve inflammation 3
• Topical antibiotics should be used with or without topical steroids when simple soaks do not relieve the inflammation 3
• The presence of an abscess should be determined, which mandates drainage 3
• Oral antibiotics are usually not needed if adequate drainage is achieved unless the patient is immunocompromised or a severe infection is present 3

Considerations for Antibiotic Therapy

When considering antibiotic therapy for J.D., the following should be taken into account:

• The most likely pathogens and local resistance patterns should guide the choice of antibiotic therapy 3
• Rapid initiation of antibiotic treatment is crucial in patients with severe infections, but may not be as important for other infectious syndromes 4
• Withholding antibiotic therapy until diagnostic results are available and a diagnosis has been established seems acceptable in most cases unless septic shock or bacterial meningitis are suspected 4
• The administration of antibiotics should be prescribed in a manner to ensure optimal drug delivery to the site of infection 5
• Patient-specific characteristics should determine the optimal breadth of antimicrobial therapy 6

Specific Antibiotic Options

The following antibiotic options may be considered for J.D.:

• Topical antibiotics such as sulfamethoxazole/trimethoprim, clindamycin, and tetracyclines may be used for purulent skin and soft tissue infections 7
• Oral tetracyclines such as doxycycline, minocycline, and omadacycline may be used for the treatment of adult patients with skin and soft tissue infections 7