Paronychia: Incision and Drainage

A localized infection at the nail fold and/or around the nail plate

INDICATIONS

Failed spontaneous drainage or improvement despite warm soaks

CONTRAINDICATIONS

Herpetic whitlow

Coagulopathy

General Basic Steps

Analgesia

Incision and drainage

Irrigation

Packing and dressing

Ensure follow-up

TECHNIQUE

Perform digital block under sterile setting

Using a no. 11 blade make an incision parallel to the nail at the area of maximal fluctuance (FIGURE 71.1)

For large paronychia, elevate the nail fold from skin and express pus

Irrigate cavity with isotonic saline under pressure, using a splash guard

Insert a small piece of packing gauze, creating a wick to allow drainage

Apply gentle nonadhesive dressing and ensure follow-up in 24 to 48 hours

COMPLICATIONS

Osteomyelitis

Abscess

Extension of infection

Destruction of nail matrix, compromising nail growth

SAFETY/QUALITY TIPS

Procedural

Drainage can sometimes occur by lifting the nail fold skin with a sterile 18-gauge needle

The proximal part of the nail may need to be removed to ensure maximal drainage of pus

Extensive infections may require surgical debridement

Cognitive

Provide antistaphylococcal/antistreptococcal antibiotic coverage with overlying cellulitis, especially in patients with underlying diabetes or other immunocompromising condition

Hand surgical consultation is appropriate in the setting of extensive cellulitis, osteomyelitis, or tumor

Paronychia can be difficult to distinguish from herpetic whitlow, and draining whitlow is contraindicated. See Chapter 72 (Felon: Incision and Drainage) for tips on identifying whitlow.