A 36-year-old woman comes to the office due to worsening pain and swelling of her left third finger. The symptoms began 3 days ago with redness at the lateral margin of the fingernail. The patient recently received a manicure at a new salon. She has had no similar symptoms in the past. The patient is a laboratory technician and uses gloves regularly while working. She was treated for a positive tuberculin skin test 10 years ago, but her medical history is otherwise unremarkable. The patient smokes a pack of cigarettes daily, drinks 2-4 beers on weekend nights, and does not use illicit drugs. Temperature is 36.6 C (97.9 F), blood pressure is 128/76 mm Hg, and pulse is 68/min. Examination shows erythema, edema, and tenderness of the lateral nail fold of the left third finger. There is no fluctuance, and the nail appears normal. The remainder of the examination shows no abnormalities. Which of the following is the best next step in management of this patient's condition?

Question

A 36-year-old woman comes to the office due to worsening pain and swelling of her left third finger.  The symptoms began 3 days ago with redness at the lateral margin of the fingernail.  The patient recently received a manicure at a new salon.  She has had no similar symptoms in the past.  The patient is a laboratory technician and uses gloves regularly while working.  She was treated for a positive tuberculin skin test 10 years ago, but her medical history is otherwise unremarkable.  The patient smokes a pack of cigarettes daily, drinks 2-4 beers on weekend nights, and does not use illicit drugs.  Temperature is 36.6 C (97.9 F), blood pressure is 128/76 mm Hg, and pulse is 68/min.  Examination shows erythema, edema, and tenderness of the lateral nail fold of the left third finger.  There is no fluctuance, and the nail appears normal.  The remainder of the examination shows no abnormalities.  Which of the following is the best next step in management of this patient's condition?

Quizplus · Accepted Answer

Explanation: This patient has acute paronychia, which is a localized bacterial infection of the nail fold. Most cases arise when injury (eg, overzealous manicuring) to the nail fold or cuticle allows invasion by gram-positive skin flora. Injury due to nail-biting or thumb-sucking can also cause paronychia due to infection by oral flora (eg, Eikenella, Fusobacterium). Manifestations include pain, erythema, and edema and usually begin within 2-5 days. The primary treatment for acute paronychia is warm soaks in water, Burow solution (aluminum acetate), or 1% acetic acid. Antiseptic (eg, chlorhexidine) soaks or topical antibiotics (eg, mupirocin) can also be considered. Any associated abscess should be drained with a hypodermic needle or small scalpel, although superficial abscesses often drain spontaneously by the time they are evaluated by the clinician. Oral antibiotics are usually unnecessary but may be added for severe cases or for patients who are immunocompromised. (Choice B) Chronic paronychia is an inflammatory condition of the nail fold that lasts >6 weeks and typically causes retraction or loss of cuticle and dystrophic changes of the nail. It is considered a variant of contact dermatitis and is treated with high-potency topical corticosteroids. Acute paronychia is usually treated with antibiotics, not corticosteroids. (Choice C) Oral acyclovir may be used to treat herpetic whitlow (although treatment is usually not needed). Symptoms include a mild prodrome (eg, fever, malaise) followed by the development of a focal area of grouped vesicles on an erythematous base. grouped vesicles (Choice D) Oral terbinafine is an antifungal that is indicated for treatment of onychomycosis. Onychomycosis is characterized by chronic discoloration and dystrophy of the nail plate. Although onychomycosis may occasionally lead to injury of the adjacent nail fold and predispose to paronychia, this patient's nail is normal. (Choice E) Infection with abscess in the digital pulp (felon) may occasionally complicate untreated paronychia and presents with severe pain in the ventral fingertip, cellulitis, and fluctuance. These cases typically require surgical drainage with debridement of the abscess cavity and systemic antibiotics. However, surgery is not needed for this patient's uncomplicated paronychia. Educational objective: Acute paronychia is a localized bacterial infection of the nail fold. Most cases are due to gram-positive skin flora. Initial management includes warm soaks; antiseptic agents or topical antibiotics can also be used. Associated abscesses should be drained, but oral antibiotics are not usually needed. References: Acute and chronic paronychia. (http://www.ncbi.nlm.nih.gov/pubmed/28671378)

A 36-Year-Old Woman Comes to the Office Due to Worsening