Paronychia

I've put all my musculoskeletal notes into this blog - as otherwise the other one is going to get pretty full. It's only one core presentation, but musculoskeletal covers a lot!

Paronychias
http://lifeinthefastlane.com/minor-injuries-007/
http://journals.lww.com/em-news/Fulltext/2010/11000/InFocus__Fingertip_Problems__Acute_Paronychia.5.aspx 
http://journals.lww.com/em-news/Fulltext/2003/09000/The_Clinical_Approach_to_Paronychia.15.aspx 
http://academiclifeinem.com/trick-of-the-trade-toe-paronychia-splinting/ 
http://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=3

Inflammatory involvement of the fold of the nail on the radial or ulnar side. 

Picture from lifeinthefastlane.com who borrowed it from www.aafp.org

Pus, erythema and swelling develop between the nail and nail fold causing pain and discomfort.
The most common cause is  trauma to the cuticle or nail fold, innoculating staph aureus. Cases can be related to antiretroviral therapy, and from sucking fingers. Strep pyrogenes, pseudomonas pyocyanea and proteus vulgaris have also been seen.Rapid onset of symptoms.

Management
Make a longitudinal incision parallel to the nail edge. You should be able to separate the cuticle from the underlying nail, exposing the potential space that is filled with pus. The skin is not actually incised - a bonus for any diabetics.
Hot soaks may improve things in just 20minutes. 
Home with advice to soak in saline and wash regularly +elevation. Should be asymptomatic in 3- 5 days!
Give antibiotics if tracking cellulitis

Chronic Paronychia
This is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens or repeated paronychial infections.

Herpetic Whitlow - don't cut it! 
http://pedemmorsels.com/herpetic-whitlow-dont-cut-it/

http://drhem.com/tag/herpetic-whitlow/

These happen commonly in children, adolescents/adults (may be associated with genital HSV) and adults (medical professionals who get inoculated by patients).
It starts with pain + tingling, then swelling and redness, constitutional symptoms. Then you get 1 or more vesicles that enlarge. Remain for 7 - 10 days, then crust over. Peeling occurs in a week.

Treatment: check other mucous membranes for vesicles, don't incise, pain management, dry dressings, needle aspiration of larger tense vesicles, aciclovir - controversial evidence.




Be careful your paronychia or whitlow it isn't a mimic:
• Squamous cell carcinoma
• Malignant melanoma
• Malignant tumors
• Eczema or psoriasis
• Reiter’s syndrome