Rosen & Barkin's 5-Minute Emergency Medicine Consult (511 page)

• Mild to moderate disease without medications
  
• Moderate to severe disease with medications and urgent neurologic outpatient follow-up
  

Discuss prevention strategies in disease management

• Diagnosis is often difficult; keep in mind other conditions commonly misdiagnosed as PD
  
• Sudden withdrawal of dopaminergic medications can result in parkinsonism-hyperpyrexia syndrome, a medical emergency
  

• Chou KL. In the clinic. Parkinson disease.
  Ann Intern Med
  . 2012,157:ITC5-1–ITC5-16.
  
• Gazewood JD, Richards DR, Clebak K. Parkinson disease: An update.
  Am Fam Physician
  . 2013;15:267–273.
  
• Grinberg LT, Rueb U, Alho AT, et al. Brainstem pathology and non-motor symptoms in PD.
  J Neurol Sci
  . 2010;289:81–88.
  
• Kipps CM, Fung VSC, Grattan-Smith P, et al. Movement disorder emergencies.
  Mov Disord
  . 2005;20:322–334.
  
• Newman EJ, Grosset DG, Kennedy PG. The parkinsonism-hyperpyrexia syndrome.
  Neurocrit Care
  . 2009;10:136–140.
  
• Worth PF. How to treat Parkinson’s disease in 2013.
  Clin Med.
  2013;13:93–96.
  

CODES

• 332.0 Paralysis agitans
  
• 332.1 Secondary parkinsonism
  
• 333.0 Other degenerative diseases of the basal ganglia
  

BASICS

• Disruption of the seal between the nail plate and the nail fold may allow entry of bacteria into the eponychial space.
  
• Inflammation of the nail folds surrounding the nail plate
  

• Acute paronychia: Predominantly
  Staphylococcus aureus
  but also streptococci,
  Pseudomonas
  , and anaerobes
  
• Chronic paronychia: Multifactorial due to allergens and irritants in addition to fungal etiologies, predominantly
  Candida albicans,
  which commonly coexist with
  Staphylococcus
  species
  

DIAGNOSIS

• Pain, warmth, and swelling to the proximal and lateral nail folds, often 2–5 days after trauma
  
• Symptoms must be present for 6 wk to meet criteria for a chronic paronychia.
  

• Acute paronychia: Nail biting, finger sucking, aggressive manicuring or manipulation, and trauma predispose to development.
  
• Chronic paronychia: Occupations with persistent moist hands; dish washers, bartenders; also increased in patients with peripheral vascular disease or diabetes
  

Frequently anaerobic mouth flora in children from nail biting

• Begins as swelling, pain, and erythema in the dorsolateral corner of the nail fold bulging out over the nail plate
  
• Progresses to subcuticular/subungual abscess
  
• Green nail coloration suggests
  Pseudomonas
  
• Nail plate hypertrophy suggests fungal source
  

• History and physical exam with special attention to evaluating for concomitant infections such as felon or cellulitis
  
• Assess tetanus status.
  

• No specific tests are useful.
  
• Cultures are not routinely indicated.
  
• Tzanck smear or viral culture if herpetic whitlow suspected.
  

Soft tissue radiographs if foreign body is suspected; routine films if osteomyelitis suspected

Digital pressure test (opposing the thumb and the affected finger) may help identify the margins of an early subungual abscess

• Felon
  
• Herpetic whitlow
  
• Trauma or foreign body
  
• Primary squamous cell carcinoma
  
• Metastatic carcinoma
  
• Osteomyelitis
  
• Psoriasis
  
• Reiter syndrome
  
• Pyoderma gangrenosum
  
• Onychomycosis
  

TREATMENT

• Early paronychia without purulence may be managed with warm-water soaks 4 times a day with or without oral antibiotics; may also consider topical antibiotics and corticosteroids.
  
• Early superficial subcuticular abscess:
  
  • Elevation of the eponychial fold by sliding the flat edge of a no. 11 blade (18G needle or small clamps may be used) gently between the proximal nail fold and the nail plate near the point of maximal tenderness
    
  • A digital nerve block or local anesthesia may be necessary.
    
• Partial nail involvement:
  
  • If the lesion extends beneath the nail, remove a longitudinal section of the nail.
    
  • Petroleum jelly or iodoform gauze packing for 24 hr
    
• Runaround abscess:
  
  • If the lesion extends beneath the base of the nail to the other side, remove 1/4–1/3 of the proximal nail with 2 small incisions at the dorsolateral edges of the nail fold and pack eponychial fold with petroleum jelly or iodoform gauze to prevent adherence.
    
• Extensive subungual abscess:
  
  • Remove entire nail.
    
• Early paronychia without purulence present may be managed with warm soaks alone; beyond that, antibiotics are recommended if there is any apparent cellulitis, abscess, or systemic sign of infection.
  
• Trimethoprim–sulfamethoxazole, dicloxacillin, and amoxicillin–clavulanate are appropriate first-line agents, with treatment regimens ranging from 5–10 days, depending on severity.
  
• Clindamycin or amoxicillin–clavulanate if associated with nail biting or oral contact
  

• Avoidance of predisposing exposures and irritants/chemicals
  
• Topical steroids should be considered first-line therapy, with or without broad-spectrum topical antifungal agent
  
• Consideration for antistaphylococcal regimen
  
• For recalcitrant cases:
  
  • Eponychial marsupialization involving removal of a crescentic piece of skin just proximal to the nail fold, including all thickened tissue down to but not including germinal matrix
    
  • Oral antifungal therapy
    

• Amoxicillin–clavulanate: 875 mg PO BID for 7 days (peds: 25 mg/kg/d PO q12h)
  
• Trimethoprim–sulfamethoxazole (Bactrim DS) BID for 7 days
  
• Dicloxacillin: 500 mg PO QID for 7 days (peds: 12.5–50 mg/kg/d PO q6h)
  

• Clindamycin: 300 mg PO QID for 7 days (peds: 20–40 mg/kg/d div. q6h PO, IV, IM)
  
• Topical antibiotics: Polymyxin B/Bacitracin, there is a high incidence of hypersensitivity to neomycin,mucipurin topical (Bactroban), or gentamicin TID for 5–10 days (0.1%ointment)
  
• Topical antifungal/steroid combination: nystatin–triamcinolone BID–TID until resolution, no longer than 1 mo
  
• For all topical antibiotics apply a small amount to affected areas TID–QID
  

FOLLOW-UP

Admission is not needed for paronychia alone.

• Patients with uncomplicated paronychias may be discharged with appropriate follow-up instructions.
  
• Patients with packings should be re-evaluated in 24 hr.
  

Chronic paronychias refractory to treatment

• Acute paronychias respond well to decompression with or without antibiotics.
  
• Chronic paronychias are largely a result of chronic exposure to allergens/irritants.
  
• Reiter syndrome and psoriasis can mimic paronychia.
  
• Recurrent paronychia should raise suspicion for herpetic whitlow.
  
• Assess for felons.
  

• Dahdah MJ, Scher RK. Nail diseases related to nail cosmetics.
  Dermatol Clin.
  2006;24(2):233–239,vii.
  
• Jebson PJ. Infections of the fingertip. Paronychias and felons.
  Hand Clin
  . 1998;14:547–555, viii.
  
• Moran GJ, Talan DA. Hand infections.
  Emerg Med Clin North Am
  . 1993;11(3):601–619.
  
• Rigopoulos D, Larios G, Gregoriou S, et al. Acute and chronic paronychia.
  Am Fam Physician
  . 2008;77(3):339–346.
  
• Rockwell PG. Acute and chronic paronychia.
  Am Fam Physician
  . 2001;63(6):1113–1116.