• Infection in the skin fold (or paronychium) to lateral edge of the nail (of the finger or toe, but most commonly finger).
• Leads to a pus filled abscess.
• Can result in cellulitis of the digit, and any other complications usually seen with this.
• Is often very painful.
• Common in nail biting.

• There is poor evidence for the use of antibiotics in the absence of cellulitis or other predisposing factors (such as the immune suppressed)
• Drainage of the abscess is standard treatment. Seems to be effective in the absence of antibiotics.
• Antibiotics rarely effective on their own.
• However, there is little research into the treatment of this condition.

Treatment

Incision and drainage of the paronychia is standard and appears to be effective.

There are a number of ways to undertake this, here are a few.

• Use of ethyl chloride to provide some analgesic cover and incision over the abscess.
  • In my experience this works well with large well formed abscess where you can incise over the collection well. It’s quick and more or less pain free in this case.
  • Not useful where there is a small, low lying or not visible collection where it can be painful for the patient.
• Use of ring blocking the digit and either incision as above or incision under the skin fold (between the nail and skin).
  • This is useful in the above cases and some of my colleagues prefer this method in all cases.

• Soaking of the digit (in warm water for +10mins) and use of a thin blunt instrument to separate the skin fold from nail. This is a new technique to me but seems worth considering.
  • This is apparently painless.
  • The aim is to gently separate the skin fold from the nail rather than incising this.
  • You can “teach” the patient how to repeat the procedure if the abscess begins to refill.

http://https://youtu.be/qoXLIhU0EhI

You can see above the use of a needle to “lift” the nail fold. Anything flat and relatively blunt (such a splinter forceps) is effective and from a psychological point of view maybe be better tolerated than use of a needle or scalpel.

• Then dress with an antibacterial dressing (such as iodine gauze) and tell the patient not to elevate the finger to encourage drainage.
• Decide whether to prescribe antibiotics (yes, in the case of any progressive cellulitis or those immunocompromised).
• Good safety netting as with any infection.
• Review if symptoms recurrent or not settled (I usually say in three days).

Further reading

I strongly recommend going to have a look at this excellent post on ST.EMLYN’S which was my inspiration for writing this, and discusses A&P, treatment, differentials and some complications in more detail.