Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients

Fingertip Infections

The fingertip is the interface between humans and the world, including the various thorns, dirty needles, and other hazards to be found there. It is unsurprising that this is the site where hand infections most frequently occur. Although commonly encountered by hand surgeons and other physicians, fingertip infections have several mimics, and diagnosis and management is not always straightforward. Early diagnosis and treatment are key to success. As with all infections, they are more common and are more aggressive in immunosuppressed patients. This article reviews fingertip anatomy, common and uncommon fingertip infections and their mimics, and recommendations for management.

Optimal diagnosis and management of common nail disorders

Nail conditions are not only aesthetic concerns, and nail changes may be a clue to an underlying systemic diseases or infection. Without timely treatment, nail diseases can continue to worsen and significantly impair performance of daily activities and reduce quality of life. Examination of the nails is essential at every medical visit, and may uncover important findings. Brittle nail syndrome, onychomycosis, paronychia, nail psoriasis, longitudinal melanonychia, Beau's lines, onychomadesis and retronychia are common nail disorders seen in clinical practice. These conditions stem from infectious, inflammatory, neoplastic and traumatic aetiologies. Though each nail condition presents with its own distinct characteristics, the clinical findings may overlap between different conditions, resulting in misdiagnosis and treatment delays. Patients can present with nail plate changes (e.g. hyperkeratosis, onycholysis, pitting), discolouration, pain and inflammation. The diagnostic work-up of nail disease should include a detailed history and clinical examination of all 20 nail units. Dermoscopy, diagnostic imaging and histopathologic and mycological analyses may be necessary for diagnosis. Nail findings concerning for malignancy should be promptly referred to a dermatologist for evaluation and biopsy. Nail disease management requires a targeted treatment approach. Treatments include topical and/or systemic medications, discontinuation of offending drugs or surgical intervention, depending on the condition. Patient education on proper nail care and techniques to minimize further damage to the affected nails is also important. This article serves to enhance familiarity of the most common nail disorders seen in clinical practice. It will highlight the key clinical manifestations, systematic approaches to diagnosis and treatment options for each nail condition to improve diagnosis and management of nail diseases, as well as patient outcomes.Key messagesNail disease is not only a cosmetic issue, as nail changes can indicate the presence of a serious underlying systemic disease, infection or malignancy.Nail pain and changes associated with NP are physically and emotionally distressing and may contribute to functional impairment and diminished quality of life.LM is a hallmark sign of subungual melanoma and this finding warrants further investigation to rule out malignancy.

Imbalanced Dermic Microbiome Aggravates Inflammation in Toenail Paronychia

The commensal microbiome influences skin immunity, but its function in toenail health remains unclear. Paronychia is one of the most common inflammatory toenail diseases, but antibiotic treatment is seldom effective in clinical cases. In this study, we performed 16S rRNA sequencing to investigate the characteristics of microbes associated with paronychia in order to identify the key microorganisms involved in inflammation. Seventy dermic samples were collected from patients with paronychia and the differences in dermic microbiota were analyzed in patients with different inflammation severities. Distinct clustering of dermal microbiota was observed in the dermis with different inflammation severities. A higher relative abundance of anaerobic microorganisms such as Parvimona, Prevotella, and Peptoniphilus was observed in severe paronychia, whereas Lactobacillus disappeared with disease progression. Co-occurring network analysis suggested that the disturbance of the dermic microbiome and attenuation of antagonism by Lactobacillus against anaerobic pathogens may aggravate inflammation in paronychia. Functional analysis showed that dermic microbiome disturbance may worsen microbial metabolism and tissue repair in the skin. In conclusion, we revealed that an increased abundance of anaerobic microorganisms and loss of Lactobacillus in the dermis may promote paronychia progression and microbiological imbalance may aggravate inflammation in patients with paronychia.

Homogenization of the management of acute paronychia with abscess formation within the context of an evaluation of professional practices

INTRODUCTION

There is no consensus in the literature, or even within the same team, on the most appropriate treatment option for acute paronychia with abscess formation. The performance of an evaluation of professional practices (EPP) using a clinical audit measures the quality of our practices with the aim of standardizing them. Therefore, the primary objective of this study was to develop a clinical pathway for the management of acute paronychia with abscess formation. The secondary objectives were to evaluate our professional practices using a clinical audit before and after the dissemination of the clinical pathway and then recommend strategies for improving our management of acute paronychia with abscess formation.

MATERIALS AND METHODS

A working group was established that designed an audit grid comprised of 15 items. Thirty patients (Group 1) who had an acute paronychia with abscess formation were included and their health records were analyzed using this audit grid. The working group then developed a clinical pathway for the management of acute paronychia with abscess formation. Thirty new patients (Group 2) were included after the dissemination of this clinical pathway and their records were analyzed using the same audit grid.

RESULTS

Our clinical pathway for the management of acute paronychia was validated by the local infectious disease committee of our university hospital center. The difference between groups 1 and 2 was significant (p<0.05) for eight items. There was no significant difference in the rate of surgical revision between the two groups.

DISCUSSION

This EPP enabled us to develop a clinical pathway that detailed the processes for managing acute paronychia with abscess formation, and in particular it provided indications for antibiotic therapy and its limitations.

LEVEL OF EVIDENCE

IV, retrospective study.

[Paronychia and Felons - Surgical Treatment]

Infections of the distal phalanx are the most common of all hand infections. There are dorsal localised infections, which develop in the area of the nail and are called paronychia, and palmar infections, which affect the fingertip and are the typical felons. The acute paronychia must be specifically opened depending on the site of infection. This requires precise anatomical knowledge of nail structure. Chronic paronychia usually have other causes and treatment is much more difficult. Felons are often extremely painful. There is a complex system of fibrous septa and swelling is limited. If the septa are destroyed a spread into the bones or the flexor tendon sheath is possible.

Advanced finger infection: more frequent than expected and mostly iatrogenic

Some patients present at an advanced stage of their fingertip infection with an extension of the infection in anatomical spaces or into fragile structures. One hundred and twenty-five patients have been operated on for a finger infection. Forty-one patients (33%) have been treated at the "complication" stage, while 84 cases (67%) were considered "non-complicated". The delay between initial injury and the surgical treatment was 12 days in the "non-complicated" group versus 30 in the "complication" group (p < 0.001). Osteitis (39% of the complications), and flexor sheath infection (37%) were the most frequent complications. Prescribing preoperative antibiotics increases the risk of being in the "complicated" group at p = 0.09. One hundred and thirteen patients (90.4%) were cured of their infection after a single operation. Neither the cause of infection, nor the type of germ or associated diabetes increased the risk of complication in our series. A better education of the first interveners (general practitioner or emergency doctor) in hand infection care could reduce the rate of complication allowing a faster access to hand surgeons.

Bacterial and Viral Infections of the Nail Unit

Bacterial and viral infections of the nail unit are very common as primary infections, especially bacterial paronychia and warts, but they can also be superinfections complicating other nail disorders. In many nail unit infections, the clinical presentation is nonspecific: in these cases, diagnostic tests are mandatory before treatment, to avoid spread of the infection and drug resistance. The most common forms of bacterial and viral infections that may affect the nail unit are herein described in detail, with diagnostic and treatment options provided.

Fingertip Infections

The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic conditions that may mimic common fingertip infections and about which the managing provider must be aware are presented.

Hand Infections

Hand infections can lead to debilitating and permanent disability, particularly if they are not treated promptly or properly. The unique anatomy of the hand, with its numerous enclosed and confined spaces, warrants special considerations. For instance, infections in deep spaces of the hand may require surgical drainage despite an appropriate course of antimicrobial treatment. Thorough history and examination are crucial in guiding further investigations and management, particularly because there are numerous mimickers of hand infections, such as gout and pseudogout.

Acute finger-tip infection: Management and treatment. A 103-case series

INTRODUCTION

Acute fingertip infections (AFTI) are common. Surgical treatment is the norm in case of effusion. There is, however, no consensus on treatment modalities, or on adjuvant antibiotic therapy (AT). We present the results of a consecutive cohort of 103 AFTIs treated in emergency consultation.

MATERIALS AND METHOD

One hundred and one patients were treated by excision and extensive lavage under digital anesthesia, with systematic bacteriological sampling. Patient history, treatment history, location, type of bacteria, complications or recurrences and AT prescription were recorded and analyzed. All patients were reviewed at first dressing (5-7 days) and recontacted at 1 month, to record any pain, stiffness or recurrence. Three groups were distinguished: A: without preoperative AT (n=71); B: under AT before surgery (n=14); C: with postoperative AT (for severe comorbidity) (n=16).

RESULTS

Mean age was 39.7 years (range: 14-84 years). The three main types of bacteria were: Staphylococcus aureus (58.3%), polymicrobial flora (16.5%), and Streptococcus (12.6%). Mean time to first dressing was 5.7 days. There were no recurrences, whatever the bacterial type or patient group. In 5 patients in group A (8.2%), AT was later prescribed at day 5 (3 for hypercicatrization and 2 for maceration). In groups B and C, progression was unproblematic. At 1 month, all patients considered themselves cured; finger-tip sensitivity was conserved in 10, and 16 were awaiting complete nail regrowth.

DISCUSSION

Hospital admission, operative treatment under general anesthesia, and AT are factors exacerbating cost and increase the management burden of AFTI. Treatment in emergency consultation seems perfectly feasible. AT does not seem useful in the absence of severe comorbidities if resection is complete. Analysis of bacterial susceptibility and renewal of the initial dressing at 1 week enable progression to be monitored and treatment changed as necessary.

MDCT of hand and wrist infections: emphasis on compartmental anatomy

Hand and wrist infections can present with a spectrum of manifestations ranging from cellulitis to deep-space collections. The various infectious processes can be categorised as superficial or deep infections based on their respective locations relative to the tendons. Superficial hand infections are located superficial to the tendons and are comprised of cellulitis, lymphangitis, paronychia, pulp-space infections, herpetic whitlow, and include volar as well as dorsal subcutaneous abscesses. Deep hand infections are located deep to the tendon sheaths and include synovial space infections, such as infectious tenosynovitis, deep fascial space infections, septic arthritis, necrotising fasciitis, and osteomyelitis. Knowledge of hand and wrist compartmental anatomy is essential for the accurate diagnosis and management of hand infections. Although early and superficial infections of the hand may respond to non-surgical management, most hand infections are surgical emergencies. Multidetector computed tomography (MDCT), with its muliplanar reformation (MPR) and three-dimensional (3D) capabilities, is a powerful tool in the emergency setting for the evaluation of acute hand and wrist pathology. The clinical and imaging features of hand and wrist infections as evident on MDCT will be reviewed with emphasis on contiguous and closed synovial and deep fascial spaces. Knowledge of hand compartmental anatomy enables accurate characterisation of the infectious process and localise the extent of disease in the acute setting.