Can Doxycycline Treat Nail Fungus

Continuing Education Activity

Paronychia is an infection of the proximal and lateral toenail and fingernail folds which may occur spontaneously or post-obit trauma or manipulation. It is 1 of the most common infections of the hand, and it is essential to know how to care for it appropriately. This activity reviews the cause, presentation, and pathophysiology of paronychia and highlights the office of the interprofessional team in its management.

Objectives:

• Identify the etiology and pathophysiology of paronychia.

• Review the appropriate examination and evaluation of paronychia.

• Describe the appropriate handling and management of paronychia.

• Summarize interprofessional squad strategies for improving care coordination and communication to care for paronychia successfully and improve patient outcomes.

Access free multiple choice questions on this topic.

Introduction

Paronychia is an infection of the proximal and lateral fingernails and toenails folds, including the tissue that borders the root and sides of the blast. This condition tin occur spontaneously or following trauma or manipulation. Paronychia is amongst the most common infections of the hand. Paronychia results from the disruption of the protective barrier between the smash and the nail fold, introducing bacteria and predisposing the area to infection. Acute paronychia is usually limited to one nail; all the same, if drug-induced, information technology tin can involve many nails.[i][2]

Etiology

The nomenclature of paronychia is according to the clinical presentation:

• Acute paronychia - Lasting less than six weeks, painful and purulent status; nearly frequently caused past a bacterial infection, peculiarly staphylococci.

• Chronic paronychia - Commonly caused by mechanical or chemic factors and sometimes infectious etiology like a fungal infection, especially Candida species. Take a chance factors include occupation (dishwasher, bartender, housekeeper), certain medications, and immunosuppression (diabetes, HIV, malignancy).

Classification tin besides be by etiology:

• Bacterial, commonly staphylococci

• Viral, commonly Herpes simplex virus

• Fungal, commonly Candida species

Noninfectious causes of paronychia can include contact irritants, excessive moisture, and medication reaction.[three]

Epidemiology

Paronychia is more common in women than in men, with a female-to-male ratio of 3 to 1. Usually, they affect manual labor workers or patients in occupations that crave them to accept their hands or feet submerged in water for prolonged periods (e.g., dishwashers). Eye-aged females are at the highest take chances of infection.[4]

Pathophysiology

Paronychia results from the disruption of the protective barrier between the nail and the nail fold, which is the cuticle. Trauma (including manicures and pedicures), infections (including bacterial, viral, and fungal), structural abnormalities, and inflammatory diseases (ex. psoriasis) are predisposing factors. Organisms will enter the moist nail fissure, which leads to colonization of the area. The majority of acute paronychias are due to trauma, nail-biting, aggressive manicuring, artificial nails, and may involve a retained foreign body. Infections are well-nigh unremarkably the result of Staphylococcus aureus. Streptococci and Pseudomonas are more common in chronic infections. [5] Less common causative agents include gram-negative organisms, dermatophytes, canker simplex virus, and yeast. Children are prone to astute infection due to habitual smash-biting and finger sucking, leading to direct inoculation of oral flora, which would include both aerobic bacteria (S. aureus, streptococci, Eikenella corrodens) and anaerobic bacteria (Fusobacterium, Peptostreptococcus, Prevotella, Porphyromonas spp.).[6]

History and Physical

Paronychia is most normally an acute inflammatory process causing painful redness and swelling to the lateral boom fold and is primarily diagnosed based on clinical presentation. The patient will commonly present within the first few days of infection due to the pain. History may include recent trauma, infection, structural abnormalities, or inflammatory diseases. Occupation and working surroundings are disquisitional historical findings; homemakers, bartenders, and dishwashers seem predisposed to developing chronic paronychia. Past medical history inquiry should include whatever debilitating illness like diabetes and HIV.[7] A listing of medications the patient is currently taking may help determine the cause of chronic paronychia.[8]

Physical exam for acute paronychia will reveal an erythematous, swollen, and tender lateral nail fold. If an abscess is present, there may be an area of fluctuance. If there is an uncertainty of an abscess present, a digital pressure examination may testify useful; the examiner tin practise this past applying pressure to the volar aspect of the involved digit. If an abscess is present, a larger than expected area of blanching will be visible at the paronychia and drainage volition be needed. In chronic paronychia, the smash fold may exist red and swollen, but fluctuance is rare. The nail fold may announced boggy, and the nail plate tin become thickened and discolored. Other mutual findings of chronic paronychia may be a retraction of the proximal smash fold, nail dystrophy, and loss of the cuticle.[iii]

Evaluation

To diagnose a paronychia, you lot will demand to obtain a skilful history and concrete, revealing a swollen and tender nail fold, as there is no laboratory testing or imaging that volition pb to the diagnosis. The infection is usually straightforward; however, the presence of an abscess is non e'er evident, and the digital pressure test described above tin can be used to guide y'all.

Treatment / Management

Paronychias are usually either treated with incision and drainage or antibiotics. If there is inflammation with no definite abscess, treatment can include warm soaks with h2o or antiseptic solutions (chlorhexidine, povidone-iodine) and antibiotics. Warm soaks should be for 10 to fifteen minutes, multiple times a twenty-four hours. There is non strong show recommending topical vs. oral antibiotics, and this may be physician-dependent based on experience. Antibiotic used should have staph aureus coverage. Topical antibiotics used may be a triple antibody ointment, bacitracin, or mupirocin.  In patients declining topical handling or more severe cases, oral antibiotics are an pick; dicloxacillin (250mg four times a day) or cephalexin (500mg three to four times a day). Indications for antibiotics with anaerobic coverage include patients where there is a concern for oral inoculation; this would require the addition of clindamycin or amoxicillin-clavulanate. If the patient has gamble factors for MRSA (including only not express to: recent hospitalization, recent surgery, ESRD on hemodialysis, HIV/AIDS, IVDU, resident of long term care facility), chose an antibiotic with the appropriate coverage. Options include trimethoprim/sulfamethoxazole DS (1 to 2 tablets twice a 24-hour interval), clindamycin (300 to 450mg four times a solar day) or doxycycline (100mg twice a day).[3]

If an abscess is present, the infection will require drainage. Incision and drainage are usually with a #11 scalpel, and the bract is inserted under the eponychial fold (lateral smash fold) until pus begins to drain. Local or digital cake anesthetic is by and large helpful to allow comfort to ensure consummate drainage. An abscess requires irrigation with normal saline, and if the abscess and incision site is large, the clinician tin can pack it with plain gauze for connected drainage. If the abscess extends to the nail bed or is associated with an ingrown nail, a fractional boom plate removal may be needed. If an abscess is present and not drained, it can spread under the nail to the other side and result in a "run-around abscess." This scenario may require complete removal of the boom to let adequate drainage and treatment. Warm soaks should be initiated after incision and drainage to encourage continued drainage by keeping the wound open and foreclose secondary infection. The patient should follow up with a provider in the next 24 to 48 hours to ensure drainage and to wait for signs of worsening infection. Commonly, incision and drainage is the adequate treatment of acute paronychia; all the same, if there is a meaning extension of cellulitis, oral antibiotics may exist prescribed every bit higher up.[9]

In chronic paronychia, the patient should be instructed to avoid trauma as to the hands equally much as possible. Wearing gloves is advised for manual workers. Treatment in chronic paronychia should point toward fungal etiology. Topical and systemic antifungal agents such equally itraconazole and terbinafine are options since the etiological factor in chronic blazon is mostly Candida species. Other inflammatory diseases of the digits like ingrown nails, psoriasis, etc. should accept handling every bit well. In difficult to care for chronic paronychia, other causes such every bit malignancy merit exploration.

Differential Diagnosis

Differential diagnosis of paronychia include:

ane- Cellulitis - Cellulitis is a superficial infection and will present equally erythema and swelling to the affected portion of the body with no area of fluctuance. Handling is with oral antibiotics.

ii - Felon - A felon is a subcutaneous infection of the digital pulp infinite. The area becomes warm, red, tense, and very painful due to the confinement of the infection, creating pressure level in the private compartments created by the septa of the finger pad. These require excision and drainage, usually with a longitudinal incision and blunt dissection to ensure acceptable drainage.

3 - Herpetic whitlow - This is a viral infection of the distal finger caused by HSV. Patients usually develop a burning, pruritic sensation before the infection erupts. A physical exam volition bear witness vesicles, vesicopustules, along with pain and erythema. It is important to not confuse this with a felon or a paronychia as incision and drainage of herpetic whitlow could result in a secondary bacterial infection and failure to heal.

4- Onychomycosis - This is a fungal infection of the nail that causes whitish-yellow discoloration. Sometimes difficult to care for and requires oral antibiotics instead of topical.

5- Blast Psoriasis - psoriasis tin too affect the fingernails and toenails. It may cause thickening of the nails with areas of pitting, ridges, irregular contour, and fifty-fifty raising of the nail from the smash bed.

6- Squamous cell carcinoma - Squamous cell carcinoma is mainly cancer of the skin but can as well affect the nail bed. It is a rare cancerous subungual tumor subject field to misdiagnosis as chronic paronychia.[1][10]

Prognosis

Paronychia usually has a practiced prognosis. Acute paronychia usually resolves within a few days and will rarely recur in salubrious individuals. Chronic paronychia may persist for several months or longer and may recur in predisposed patients.

Complications

Acute paronychia can cause a astringent infection of the hand and may spread to involve underlying tendons, which is why appropriate treatment on initial presentation is essential. This status may require evaluation and handling by a hand surgeon equally it often involves debridement, washout, or amputation, based on the severity of the infection. The major complication of chronic paronychia is smash dystrophy. It is ofttimes associated with brittle, distorted nail plates. Boom discoloration is non an uncommon complication of chronic paronychia.[11]

Consultations

A dermatologist can manage paronychia in the bulk of cases, but on rare occasions where in that location is interest of the deep structure and or the bones, then hand orthopedic consultation may get necessary.

Deterrence and Patient Education

Patients should go on their hands dry and warm. Recommendations include wearing gloves for whatsoever contact with water, chemicals, and irritants. Avoid nail-biting, manicuring nail folds, using nail varnish, application of false nails until complete recovery.

Pearls and Other Issues

Manicurist should stop the habit of removing cuticles from fingernails and toenails because it will create a port of entry for a variety of organisms and ultimately leads to colonization. Surgical intervention may be necessary for more than severe cases. In patients with frequent recurrences, permanent nail ablation can be beneficial.

Enhancing Healthcare Team Outcomes

Assessment of any patients with a paronychia requires total, detailed history and proper physical examination. The patient history is essential, and it might requite a clue for the triggering factors. Appropriate treatment is crucial as this can prevent worsening infections and complications.

Paronychia requires an interprofessional team arroyo, including physicians, specialists, specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level Five] In most cases, the clinician (physician, NP, PA) will diagnose and prescribe handling. Pharmacists can recommend antimicrobial therapy, whether fungal or bacterial and written report back to the nurse or clinician if they accept any concerns. Pharmacists can also bank check for drug-drug interactions, and let the nurse or physician know if they are present. Nurses and pharmacists tin can both verify patient compliance and counsel patients on their medications or the dosing/administration of the aforementioned, and study whatever issues dorsum to the prescribing clinician, who can make changes to the patient's drug regimen based on patient needs.

Review Questions

Figure

Acute Paronychia. Contributed by DermNetNZ

Figure

Paronychia, Chronic. Contributed by DermNetNZ

Figure

Astute paronychia. Contributed by Daifallah M. Al Aboud, M.D.

Figure

Chronic paronychia. Contributed by Daifallah M. Al Aboud, M.D.

Figure

Paronychia. Image courtesy S Bhimji MD

References

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Sampson B, Lewis BKH. Paronychia Associated with Ledipasvir/Sofosbuvir for Hepatitis C Treatment. J Clin Aesthet Dermatol. 2019 Jan;12(1):35-37. [PMC free article: PMC6405246] [PubMed: 30881576]

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Leggit JC. Acute and Chronic Paronychia. Am Fam Md. 2017 Jul 01;96(1):44-51. [PubMed: 28671378]

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Black JR. Paronychia. Clin Podiatr Med Surg. 1995 Apr;12(2):183-7. [PubMed: 7600493]

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Natsis NE, Cohen PR. Coagulase-Negative Staphylococcus Skin and Soft Tissue Infections. Am J Clin Dermatol. 2018 Oct;nineteen(five):671-677. [PubMed: 29882122]

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Brook I. The part of anaerobic bacteria in cutaneous and soft tissue abscesses and infected cysts. Anaerobe. 2007 October-Dec;thirteen(5-half dozen):171-7. [PubMed: 17923425]

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Kapellen TM, Galler A, Kiess W. College frequency of paronychia (boom bed infections) in pediatric and adolescent patients with blazon i diabetes mellitus than in not-diabetic peers. J Pediatr Endocrinol Metab. 2003 Jun;16(5):751-eight. [PubMed: 12880125]

8.

Goto H, Yoshikawa S, Mori Thousand, Otsuka Grand, Omodaka T, Yoshimi 1000, Yoshida Y, Yamamoto O, Kiyohara Y. Effective treatments for paronychia acquired by oncology pharmacotherapy. J Dermatol. 2016 Jun;43(6):670-3. [PubMed: 26596962]

nine.

Pierrart J, Delgrande D, Mamane West, Tordjman D, Masmejean EH. Acute felon and paronychia: Antibiotics not necessary later on surgical treatment. Prospective study of 46 patients. Mitt Surg Rehabil. 2016 Feb;35(one):40-three. [PubMed: 27117023]

10.

Patel DB, Emmanuel NB, Stevanovic MV, Matcuk GR, Gottsegen CJ, Forrester DM, White EA. Paw infections: anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics. 2014 Nov-Dec;34(7):1968-86. [PubMed: 25384296]

11.

Graat LJ, Bosma E. [A woman with a bloated finger]. Ned Tijdschr Geneeskd. 2010;154:A988. [PubMed: 20699023]

Source: https://www.ncbi.nlm.nih.gov/books/NBK544307/

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