Topic

• Introduction
• Indications
• Contraindications
• Procedure
• Coding Information

Figure(s)

• Paronychia Block
• Elevation of the Nail Fold to Drain Abscess
• Excision of the Proximal Nail Fold

• Paronychia is superficial infection or abscess of tissues bordering nails (i.e., nail folds). Infections develop when disruption occurs between the seal of the proximal nail fold and nail plate.
• Acute paronychia manifests with rapid development of erythema and swelling in proximal or lateral nail fold. Infection with Staphylococcus aureus, streptococci, or Pseudomonas species is most common.
• Mild cases can be soaked in warm water or treated with topical or oral antibiotics (i.e., amoxicillin and clavulanic acid or clindamycin to cover oral anaerobes).
• Chronic paronychia must have been present for at least 6 wks. These lesions often develop slowly and insidiously, and they may be associated with low-grade infections with Candida albicans. Chronic paronychia are common in bakers, bartenders, dishwashers, or thumbsuckers who expose their hands to repeated or prolonged moisture and irritation.
• Women in their middle reproductive years are most commonly affected, with some series reporting female-to-male ratios of 10:1. Secondary nail plate changes may be found, including onycholysis (i.e., separation), lateral greenish brown discoloration, and transverse ridging.
• Elimination of offending activities or agents and treatment with antifungal agents and topical or oral corticosteroids are advocated. Although medical therapy is a mainstay of treatment for paronychia, surgical therapy provides benefit for nonresponders.
• Advanced cases of acute paronychia should be incised and drained. Advanced cases of chronic paronychia result in disappearance of the cuticle with retraction of the proximal nail fold from the underlying nail plate. Chronic paronychia can be treated with an eponychial excision technique or by nail removal. Almost all of the surgical procedures have medications included in the therapeutic approach.

• Abscess formation or severe pain in acute paronychia
• Lack of response to medical therapy and avoidance of moisture and irritation
• Deformity (i.e., loss of proximal nail fold) in chronic paronychia

Relative Contraindications

• Unfamiliarity of practitioner with techniques
• Bleeding diathesis or coagulopathy
• Chronic paronychia surgery in unreliable patient or person unable to provide wound care

• Digital block is commonly performed (see Chap. 29, Digital Nerve Block) before surgery, although some practitioners prefer no anesthesia or a paronychia block when treating acute paronychia.
  • Paronychia block uses a small (27- to 30-gauge) needle inserted from lateral side near distal interphalangeal joint, proximal to paronychia.
  • Administer 1–3 mL of 1% lidocaine at this site (Fig. 33-1).
• Swelling of proximal and lateral nail fold is associated with an abscess of acute paronychia (Fig. 33-2A).
  • No. 15 scalpel blade is laid flat on top of the nail plate, with the tip of the blade directed to the center of the abscess or fluctuance (Fig. 33-2B). Alternately, a no. 11 blade can be used, especially if additional depth of insertion is needed.
  • Guide the blade gently along the nail surface under the nail fold, and then elevate the tip, pulling the nail fold upward (Fig. 33-2C). The nail plate acts as a fulcrum; pushing down on the back of the blade (or blade handle) causes the tip to elevate.
  • A large amount of pus may drain on the top of the nail plate (Fig. 33-2D). Pus can be squeezed from beneath the nail and through a small opening. This technique has the advantage of the absence of a skin incision. An alternate technique produces an incision through the nail fold, with drainage through the skin.
  • Pitfall: Failure to elevate the tissue sufficiently may permit pus to remain in the site. Because the opening over the nail plate is small and does not involve an incision, the site can reseal and the abscess redevelops. Several sites along the nail fold may require elevation to ensure adequate drainage, and the patient should be reexamined in 2 days to check for reformation of paronychia.
• Chronic paronychia can be treated with excision of the proximal nail fold.
  • After digital block, use a Freer septum elevator to separate the proximal nail fold from the nail plate (Fig. 33-3A). A flat elevator is then positioned beneath the proximal nail fold to protect the underlying tissues during excision.
  • A crescent-shaped, full-thickness incision is made in the proximal nail fold (Fig. 33-3B). The incision extends from 1 lateral nail fold to the other. An island of skin to be removed is 5 mm wide (Fig. 33-3C), incorporates the entire swollen portion of the proximal nail fold and extends to just proximal to proximal the nail plate (Fig. 33-3D).
  • The side heals by secondary intention after 2 months, with resulting nail revealing more visible lunula.
  • An alternate technique is to remove the entire nail, placing antifungal and steroid ointment on the site daily.
  • Pitfall: Meticulous wound care is required after this procedure, and surgery is appropriate only for patients who are able and willing to provide this care. Some physicians apply combination antifungal and steroid ointment at night and antibiotic ointment during the day until the wound heals.

Codes for incision and drainage (I&D) are provided in the following chart.

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