Oral antibiotics for paronychia: unexpected outcomes of ‘killing a fly with a cannon’

The recommended treatment for mild paronychia is conservative. Warm compresses or soaks are used, along with topical antibiotics with or without topical steroids.  If an abscess has formed around the nail, incision and drainage is added. Oral antibiotics are only recommended in refractory cases or in patients with comorbidities such as diabetes or immunosuppression.

We share two salutary tales of complications arising from oral antibiotic therapy for this relatively minor condition:

Case 1 from JAMA Internal Medicine : An 80 year old woman, with a past medical history of asthma and eczema, presented with 1-2 weeks of  pain in one finger.  She was noted to have a swollen, erythematous and tender nail fold without pus of nail discoloration. A diagnosis of acute paronychia was made and the patient was instructed to use warm compresses and prescribed a course of oral trimethoprim+sulfamethoxazole.

Six days after starting the antibiotics she developed a rash involving the face, trunk and extremities. The antibiotic was discontinued and an oral antihistamine and a topical steroid cream commenced.

Three days after that the patient presented to the emergency department. The rash had not improved and she was now experiencing decreased appetite and generalised malaise. She appeared dehydrated and laboratory tests showed hypernatraemia, elevated creatinine and eosinophilia. A dermatology consult raised concerns that the patient was experiencing drug-induced hypersensitivity syndrome. that then required inpatient management with rehydration and  methylprednisolone.

Case 2, recent local admission : a 78 year old woman with nonalcoholic steatohepatitis (NASH) and early cirrhosis presented (February 2016) with a second relapse of C. difficile infection that was initially quite severe. She has  now responded to intravenous fluids, metronidazole and vancomycin (fidaxomycin planned).  The relapse had occurred 1 week after completing an oral vancomycin taper for 4 weeks.

In November , she had developed an acute paronychia that had been managed with oral antibiotics (of an unspecified type) and developed the first bout of C. difficile in December.



One comment

  1. Christina Vandenbroucke-Grauls · · Reply

    Indeed, no need for oral antibiotics for treatment of paronychia. But here in The Netherlands we also do not use local antibiotics. There is no need for those either. We recommend local treatment with soaks or warm compresses, and, if needed, a small incision to eliminate pus, and that’s it. “Ibi pus, ibi evacua” is still the best treatment for abscesses, even small ones.


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