CASE                               27                               

A 23-year-old man presents to your office with pain of his fingertip over the past day. He does admit to biting his nails and cuticles, particularly because he is stressed over his upcoming dentistry examinations. He has slight swelling and redness over the ulnar eponychial fold of his index finger. He has tenderness to palpation, but no fluctuance is noted.

What is the diagnosis?

1. Paronychial infection

2. Finger felon

3. Distal interphalyngeal septic arthritis

4. Psoriatic arthritis

5. Herpetic Whitlow

Discussion

The correct answer is (A). This is an infection of the tissues around the fingernail. A history of biting of the nails is typical as it results in a break of the skin barrier, a source of bacteria, and a moist environment with tissue maceration. A finger felon is an infection of the fingertip pulp tissue—the pain, swelling, and redness would be volar in that situation. DIP joint septic arthritis would present with generalized swelling of the distal digit. Psoriatic arthritis often presents with pitting of the nails and nails that separate from the underlying nail bed (onycholysis). A herpetic whitlow would present with vesicle formation.

What is the most appropriate next step in management for this patient?

1. Warm soapy water soaks and oral antibiotics

2. Drainage by elevating the paronychial fold away from the nail

3. Drainage by incising over the point of maximal tenderness with the knife directed toward the nail bed and matrix

4. Removal of the ulnar half of the nail

5. Complete removal of the nail

Discussion

The correct answer is (A). Without clear fluctuance and after a short time course, oral antibiotics and soaks in warm soapy water to promote drainage are often adequate. If fluctuance is appreciated, drainage is accomplished by elevating the fold away from the nail after adequate regional block. Alternately, an incision can be

made over the point of maximal tenderness but should be directed away from the nail fold to prevent nail deformity. Partial or complete nail removal is utilized with more extensive infections often involving the eponychia and opposite paronychia, respectively.

The patient is treated with antibiotics and has a full recovery. He reports that he passed his examinations and has started his clinical rotations for dental school. However, 3 months later he represents with painful small vesicular lesions with a red base affecting his ulnar paronychia surrounding a confluent, large vesicular lesion extending to the proximal phalanx of his thumb.

What is the most appropriate next step in management?

1. Observation

2. Oral antibiotics and warm soapy soaks

3. Drainage of the infection by elevating the paronychial fold away from the nail.

4. Removal of one half of the nail

5. Removal of the complete nail

Discussion

The correct answer is (A). The vesicular lesions are consistent with a Herpetic Whitlow, or cutaneous Herpes Simplex Virus Infection. Dental workers are at a higher risk because of contact with oral herpetic infections. Young children who suck on their fingers and have an oral infection are also at risk. The condition is usually self-limited, but antivirals are used when the condition is not improving, worsening, or very painful. Surgeons will often receive pressure to drain these infections, but surgical drainage is contraindicated as it does not affect the course of the viral infection and can cause significant wound healing problems, or encephalitis via hematogenous spreading.

Objectives: Did you learn...?

Describe the presentation of paronychial infection? Understand its management?

Describe the management of herpetic whitlow?