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Boils, carbuncles, folliculitis, paronychia and staphylococcal whitlow - Management
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Definition
- Paronychia is infection bordering the nail which causes painful swelling and possibly a visible collection of pus.
For someone with a suspected boil, carbuncle, folliculitis, acute paronychia or staphylococcal whitlow, what assessment do I need to make?
- Size and position of the lesion.
- Presence of pus or fluctuance (wave-like feeling on palpating skin overlying a fluid-filled cavity with nonrigid walls).
- Symptoms suggesting systemic spread of infection.
- Whether a swab is required.
In depth
Do I need to take a swab (boils, carbuncles, folliculitis, paronychia, staphylococcal whitlow)?
- Swabs are not routinely required for initial management.
- Swabs are indicated if the lesion is getting worse over 48 hours despite antibiotic treatment, or there is no response to empirical antibiotic treatment within 5–7 days.
In depth
How do I manage acute paronychia with fluctuance?
- Incise and drain (this can be done locally if the skills to do this exist within the practice, or alternatively refer).
- Offer antibiotics if:
- There is also fever or cellulitis.
- There are other comorbidities (e.g. diabetes).
- Offer analgesia (paracetamol or ibuprofen) if needed.
In depth
How should I manage acute paronychia without fluctuance?
- Advise the use of warm soaks three to four times a day.
- Treat empirically with oral antibiotics.
- Offer analgesia (paracetamol or ibuprofen) if needed.
In depth
Which antibiotic should I prescribe (if indicated)? (boils, carbuncles, folliculitis, paronychia, staphylococcal whitlow)
- Oral flucloxacillin is recommended for empirical treatment.
- Oral erythromycin (or clarithromycin if erythromycin is not tolerated) is an alternative for people with penicillin allergy.
In depth
How long should I prescribe antibiotics for? (boils, carbuncles, folliculitis, paronychia, staphylococcal whitlow)
- A 7-day course of empirical antibiotic treatment is recommended.
In depth
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:
- If the person is able to take penicillin, change the antibiotic to co-amoxiclav.
- 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 frequently wet hands).
- Swab for mycological culture, and if positive for candida, treat with a topical imidazole or consider oral treatment if the person is immunocompromised.
- If candidal paronychia is associated with nail infection, see the CKS topic on Fungal nail infection.
In depth
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