Very frequently, this won’t heal with soaking and antibiotics, we’re gonna need to be a bit more proactive than that!
In a couple of years, I will have been in clinical practice for 40 years…… That’s harder to type than it was to achieve. The point of this frightening statistic is that over that period, you begin to see patterns appear and disappear just as unexpectedly. Today’s blog subject is just such a situation. Over the last few weeks, we have had seven cases between our Brantford and Mississauga Podiatry Associates offices, and last weekend’s Facebook Podiatrist had two cases posted by patients for community comments.
This condition is called Paronychia :
According to Dr Google Paronychia is an infection of the proximal and lateral fingernails and toenails folds, including the tissue that borders the root and sides of the nail. This condition can occur spontaneously or following trauma or manipulation.
Typically, treatment will involve gentle debridement, drainage of pus or fluids, soaking, application sterile dressing and prescription of an appropriate oral antibiotic.
Most commonly, these patients present to emergency clinics and family practitioners. Following a couple of courses of antibiotics, they appear in our offices, in great pain, and generally quite distraught at their lack of progress. In truth, there was nothing wrong with the initial management, but in a high number of cases, the infected area is unable to drain properly, and as a result, the residual infected material starts the process all over again.
So before we talk about treating this scenario, how did it arise in the first place?
Most commonly, infectious paronychia results from a staph infection. Staphylococcus aureus bacteria cause staph infections. Other bacteria (such as Streptococcus pyogenes) can also cause the infection. Bacteria get into the skin through:
- Cuts, broken skin or hangnails.
- Ingrown nails (this happens most often with ingrown toenails).
- Irritation from water or chemicals.
- Trauma to the nailbed or cuticle area. Trauma can result from accidents, frequent pedicures and associated destruction of the cuticle
- Biomechanical trauma that is unique to specific sports footwear .
- Some medications can also cause paronychia. Some of these medications include retinoids, anti-cancer medications, HIV medications and some antibiotics.
Most bacterial infections tend to spread along tissue planes. Meaning that, if the bacteria manage to penetrate the membrane from the nail fold to the area between the nail plate and nail bed, it can remain untouched by the circulating antibiotics, only to re-emerge.
Understanding this scenario, we can now break the cycle and enable resolution. We do this by first giving a gentle local anesthetic to freeze the toe. Then, without damaging the nail bed, we gently separate the nail from the bed, flush the nail fold of all infected material and apply a sterile dressing.
The patient then proceeds with twice-daily saline soaks and finishes their antibiotic regimen. Once healed, simple emollient use daily keeps the nail-bed soft and supple until the new nail has grown back. With minimal trauma to the nail-bed, the new nail will be of normal shape, thickness, with almost immediate relief from the often intense pain.
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