›Evidence supports epinephrine safety in digital blocks but avoid in vascular disease
›Single-injection volar technique as alternative
›2–3 mL lidocaine 1% injected volar midline at digit base
›Drainage technique — lateral nail fold abscess
›Simple paronychia technique
›18-gauge needle or #11 blade along the margin of nail fold
›Lift nail fold off nail plate to allow pus to drain
›No incision into skin required in many cases
›Culture wound drainage if indicated
›Eponychia and runaround abscess
›Single incision at most involved lateral fold
›Double incision technique if bilateral involvement
›Loosely pack with iodoform gauze or plain gauze
›Packing removal in 24–48 hours
›Subungual extension — partial or complete nail removal
›Partial nail avulsion
›Elevator introduced under nail plate at proximal edge
›Proximal quarter to third of nail plate elevated and removed
›Allows drainage of subungual abscess
›Full nail avulsion reserved for extensive subungual involvement
›Post-procedure care
›Non-adherent dressing applied
›24–48 hour recheck mandatory
›Nail regrowth typically 3–6 months
›Antibiotics after drainage
›Oral antibiotics generally NOT needed after adequate drainage in immunocompetent
›ACEP Level C recommendation
›Prescribe antibiotics if: immunocompromised, significant surrounding cellulitis, systemic signs, high-risk organism suspected
›Cephalexin 500 mg four times daily or TMP-SMX DS twice daily for 5–7 days
Chronic paronychia treatment
›First-line interventions
›Irritant avoidance — most important intervention
›Avoid wet work; wear cotton-lined rubber gloves for wet exposure
›Remove offending medications if possible (EGFR inhibitors — oncology coordination needed)
›Topical corticosteroids — first-line pharmacotherapy
›Clobetasol 0.05% applied twice daily to proximal nail fold
›More effective than systemic antifungals in head-to-head trials (ACEP Level B)
›Duration: 3 weeks minimum, reassess at 4–6 weeks
›Topical antifungals — adjunct therapy
›Clotrimazole 1% or ketoconazole 2% cream applied daily
›Targets Candida colonization
›Emollients and barrier repair
›Apply after each hand wash
›Restore cuticle and nail fold barrier function
›Refractory chronic paronychia — surgical options
›Eponychial marsupialization
›Crescent excision of proximal nail fold skin
›Removes reservoir of chronic inflammation
›Success rate > 90% in refractory cases
›En bloc excision of proximal nail fold
›More extensive than marsupialization
›Reserve for severe, unresponsive chronic paronychia
›Partial matricectomy
›For drug-induced paronychia (EGFR inhibitors) unresponsive to 3 months conservative therapy
›Chemical (phenol) or surgical matricectomy
Herpetic whitlow management
›Antiviral therapy — do NOT incise
›Acyclovir 400 mg orally three times daily for 7–10 days
›Or valacyclovir 1 g twice daily for 7–10 days
›Reduces duration and viral shedding
›Dressings — occlusive to prevent autoinoculation and transmission
›Advise hand hygiene to prevent spread
›Recurrent episodes
›Suppressive acyclovir 400 mg twice daily if > 6 recurrences per year
›Incision and drainage contraindicated
›Risk of bacterial superinfection
›Risk of viral dissemination and encephalitis (rare)
IV antibiotics — severe or systemic infection
›Empiric IV antibiotics for hospitalized patients
›Nafcillin or oxacillin 1–2 g IV every 4–6 hours
›MSSA coverage when MRSA risk low
›Vancomycin IV
›Target trough 15–20 mg/L or AUC/MIC 400–600
›Indication: MRSA concern, penicillin allergy, or failed beta-lactam
›Loading dose 25–30 mg/kg IV, then 15–20 mg/kg every 8–12 hours based on renal function
›Ampicillin-sulbactam 3 g IV every 6 hours
›Polymicrobial or bite-related infections
›Coverage: streptococci, MSSA, anaerobes, Eikenella
›Duration guided by clinical response and cultures
›Transition to oral antibiotics when tolerating and afebrile > 24–48 hours