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Boils, carbuncles, folliculitis, paronychia and staphylococcal whitlow - Management
What should I do if there is no response to antibiotics (acute paronychia)?

  • If there is no response to antibiotics within 5-7 days or the paronychia is getting worse over 48 hours despite antibiotic treatment:
    • Take a swab of any pus or discharge to confirm the infecting organism (choice of antibiotic should be guided by sensitivities).
    • Incise and drain if the paronychia is fluctuant and this has not already been done (this can be done locally if the skills to do this exist within the practice, or alternatively refer).
  • If there is no pus to swab, and incision and drainage of the paronychia is not appropriate:
    • Change the antibiotic to co-amoxiclav if the person is able to take penicillin.
    • If the person is allergic to penicillin, continue erythromycin (or clarithromycin if the person is unable to tolerate erythromycin) and add metronidazole.
  • If there is no response to the change in antibiotic, consider candidal infection (especially if person has the risk factor of frequently wet hands).
    • Swab for mycological culture, and if positive for candida, treat with topical imidazole.
    • If candidal paronychia is associated with nail infection, see the CKS topic on Fungal nail infection.
    • If the person is immunocompromised, consider oral antifungal treatment.
Clarification / Additional information
  • Incision and drainage can be done locally if the skills to do this exist within the practice, or alternatively refer.
  • There is only value in swabbing discharging lesions, or those that have undergone incision and drainage. Swabbing inflamed skin is not helpful.
Basis for recommendation
  • This is pragmatic advice based on the most likely causative organisms (Staphylococcus aureus, Streptococcus sp, or anaerobes) and expert opinion [Scott, 2002; McNulty, Personal Communication, 2007].
  • Anaerobes may be responsible for paronychial infection caused by nail biting or finger sucking [Lee et al, 2007].
  • If there is proximal red streaking or lymphadenopathy, consider the possibility of a mixed infection with streptococcus [Lee et al, 2003].
  • There is no evidence that oral antibiotics are any better or worse than incision and drainage for treating acute paronychia [Shaw and Body, 2005].

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