Approach to the Critical Patient

Red flags and urgent threats

Limb-threatening and systemic escalation triggers

Immediate priorities

Airway, breathing, circulation baseline

Key decision points at presentation

Monitoring and targets

Procedural monitoring

History

Onset and duration

Temporal classification

Precipitating factors

Acute precipitants

Chronic precipitants

Symptom characterization

Localization and character

Important negatives and alarm features

Differentiation clues

Risk factors

Host risk factors

Occupational and behavioral risk factors

Past medical history

Relevant comorbidities

Physical Exam

Nail fold and digit inspection

Nail fold assessment

Nail plate assessment

Digit and hand exam

Spread assessment

Regional lymphatic assessment

Systemic assessment

Vital signs

General appearance

PITFALLS

Examination pitfalls

Differential Diagnosis

Infectious differentials

Hand and finger infections

Non-infectious and malignant differentials

Inflammatory and malignant conditions

Laboratory Tests

Wound cultures

Microbiological testing

Cytologic testing

Tzanck smear

Systemic labs

Indicated for complicated or systemic presentations

Routine labs NOT indicated for uncomplicated paronychia

Diagnostic Tests

Scoring Systems

Severity and risk stratification tools

MRI

MRI of digit or hand

CT

CT of digit or hand

Ultrasound

Point-of-care ultrasound (POCUS) of digit

Disposition

Discharge criteria

Outpatient management appropriate for most cases

Admission criteria

Indications for admission

Consultation triggers

Specialist referrals

Follow-up

Post-procedure follow-up schedule

Treatment

Mild acute paronychia without abscess

Conservative management

Incision and drainage — abscess present

Digital nerve block

Drainage technique — lateral nail fold abscess

Subungual extension — partial or complete nail removal

Antibiotics after drainage

Chronic paronychia treatment

First-line interventions

Refractory chronic paronychia — surgical options

Herpetic whitlow management

Antiviral therapy — do NOT incise

IV antibiotics — severe or systemic infection

Empiric IV antibiotics for hospitalized patients

Special Populations

Pregnancy

Physiologic and management considerations

Geriatric

Age-related considerations

Pediatrics

Age-specific management

Background

Epidemiology

Prevalence and incidence

Pathophysiology

Acute paronychia mechanism

Chronic paronychia mechanism

Therapeutic Considerations

Evidence base for key management decisions

Patient Discharge Instructions

copy discharge instructions

Paronychia — Discharge Instructions

References

Guidelines and key sources

Primary clinical references

Leggit JC. Acute and Chronic Paronychia. American Family Physician. 2017; PMID 28671378

Rockwell PG. Acute and Chronic Paronychia. American Family Physician. 2001; PMID 11277548

Rigopoulos D et al. Acute and Chronic Paronychia. American Family Physician. 2008; PMID 18297959

Rerucha CM et al. Acute Hand Infections. American Family Physician. 2019; PMID 30763047

Clark DC. Common Acute Hand Infections. American Family Physician. 2003; PMID 14677662

Shafritz AB, Coppage JM. Acute and Chronic Paronychia of the Hand. JAAOS. 2014; PMID 24603826

Gottlieb M, Long B. Management of Finger Felons and Paronychia. J Emerg Med. 2025; PMID 40945390

Auquit-Auckbur I et al. Diagnosis and Management of Upper Limb Soft Tissue Infections. OTSR. 2025; PMID 41177246

Durdu M, Ruocco V. Clinical and Cytologic Features of Antibiotic-Resistant Acute Paronychia. JAAD. 2014; PMID 24355264

Robert C et al. Nail Toxicities Induced by Systemic Anticancer Treatments. Lancet Oncol. 2015; PMID 25846098

Hanania HL et al. Surgical Intervention for Paronychia Induced by Targeted Anticancer Therapies. Dermatol Surg. 2021; PMID 34029250

Signoret-Bravo MT et al. Osteomyelitis Mimicking Chronic Paronychia. JAMA Dermatology. 2026