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Three Part Question

In [a patient with an acute paronychial nail infection] is [incision and drainage superior to oral antibiotics] in [settling infection]?

Clinical Scenario

A healthy 22-year old lady attends the emergency department, complaining of a painful, red finger, which she says has come on over a couple of days. Examination reveals erythema to the side of her fingernail with a suggestion of a slight yellow centre. You diagnose an acute paronychia, but wonder whether to prescribe her a course of oral antibiotics or formally incise and drain the suspected collection.

Search Strategy

Medline 1966-02/05 using the OVID interface.
Embase 1974-02/05
Cochrane Library 2005 Issue 1: Paronychia* OR felon* OR whitow*
Medline: [(exp paronychia/ OR paronychia$.af. OR felon$.af. OR whitlow$.af. OR finger adj infection$.mp. OR digit$ adj infect$.mp. OR nail adj infection$.mp.)] AND [incision adj drainage.mp. OR drainage.af. OR exp drainage/ OR incis$.af. OR i&d.af. OR surg$.af.)] AND [exp antibiotics OR antibiotic$.af. OR exp anti-bacterial agents/ OR antibacterial$.af. OR antimicrobial$.af. OR antiinfective$.af. OR anti-biotic$.af. OR anti-microbial$.af. OR anti-infective$.af.]
Embase: [exp paronychia/ OR paronychia$.af. OR felon$.af. OR whitlow$.af.] AND [exp incision/ OR incis$.af. OR incision.af. OR drainage.af. OR exp surgical-drainage/ OR exp percutaneous-drainage/] AND [antibiotics OR exp antibiotic-agent/ OR exp anti-biotic-therapy/ OR exp antiinfective agent/ OR antibacterial.af. OR antimicrobial.af. OR antibiotic$.af. OR anti-biotic$.af. OR anti-bacterial.af. OR anti-infective.af. OR anti-microbial.af.]

Search Outcome

Medline - 73 papers, none relevant
Embase - 61 papers, none relevant
Cochrane - 72 papers, none relevant

Comment(s)

It seems to be generally accepted practice in emergency medicine that any paronychial infection with an apparent area of pus requires incision and drainage, which is painful for the patient and time consuming for the clinician. in contrast we regularly see patients who have failed treatment with antibiotics prescribed from other departments or in primary care. There is currently no evidence that surgical management confers any advantage over oral antibiotics for the treatment of paronychiae. A well-designed comparative trial may help to elucidate whether the traditional surgical approach actually leads to superior outcome. Currently our practice is to incise and drain if pus is present.

Clinical Bottom Line

There is currently no evidence that oral antibiotics are any better or worse than incision and drainage for acute paronychiae.