Preparation

• Absorbent pad
• Gloves
• Goggles
• Chlorhexidine (or other approved skin cleanser)
• 18-gauge needle
• Normal saline
• 30 mL syringe with splash guard or 16-18g IV cathlon for irrigation
• Gauze pads
• 1/4 inch ribbon packing material
• Gauze for wrapping
• Tape

Procedure Steps

Step 1: Health history and physical examination

An abscess is indicated by fluid accumulation; cellulitis is indicated by a subcutaneous cobblestone appearance. Ultrasound should be performed if physical examination alone cannot determine if an abscess is present.

Step 2: Drain abscess using the simple incision technique

Anesthesia is not typically required as the incision is in mostly necrotic tissue and is often painless.

a. Position bevel up and laid horizontally on the nail surface
b. Insert the needle at the lateral nail fold where it meets the nail and the point of maximum fluctuance
c. Use the needle to lift the nail fold to release pus
d. Use a gentle side-to-side motion to increase the size of the incision made by the needle
e. Place gentle pressure on the external skin to express as much pus as possible from the paronychia

Step 3: Irrigate the cavity with normal saline

Step 4: Insert a small piece of ribbon packing material into the cavity to facilitate continued drainage

Step 5: Cover the wound with a sterile dressing

Step 6: Provide oral antibiotics if cellulitis present

Most paronychia infections do not require antibiotics and are treated successfully with incision and drainage alone.

Aftercare

• Elevate hand or foot to reduce throbbing and pain.
• Leave packing in place for 24-48 hours to allow for continued drainage.
• Clean affected digit with soap and water after packing removed.
• Warm soaks for 10-15 minutes 3 to 4 times per day after dressing removed.
• Avoid biting nails, sucking on fingers.
• Avoid aggressive manicures.

Patient Education

Follow-up

• Arrange follow-up for packing to be removed and wound evaluation after 24-48 hours.
• Monitor for progressive infection and treat with systemic antibiotics as needed
  • Fever
  • Increasing pain after 24 hours
  • Increased redness or streaking
  • Swelling

Key Takeaways

• Treatment for acute paronychia is based on the degree of inflammation and presence of abscess.
• Incision and drainage is the ideal treatment when abscess is present.
• The simple drainage technique is typically painless as the affected tissue is mostly necrotic.
• Systemic antibiotics are not typically required.
• Consider mixed oropharyngeal pathogens as causative organism if cellulitis present.