Is it an infection or an inflammation? That’s just one of the questions about the paronychia that came up during a roundtable discussion among DPMs. They also addressed the debate over doing a P&A for a paronychia, whether soaking is the ideal treatment and what you should do differently when treating a diabetic who has a paronychia. Here are their comments.
Warren Joseph, DPM: Any of us who have had a paronychia know they hurt. These patients will come into your office and they are in pain. They’ve all been to their family doctor, their primary doctor if they’re HMO patients and universally, what does their primary physician tell them to do? Soak it. It’s almost the answer to everything.
The Medicare carrier in New York requires culturing of paronychias. If you’re going to bill a paronychia code, they require that you culture it, which is inane because let’s look at what the definition of a paronychia is. In any dictionary, a paronychia is defined as an inflammation of the nail groove or the nail lip. In fact, more likely than not, this is probably a foreign body reaction to the nail that’s now penetrating into the tissue. It is not, by definition, an infectious process.
We also know the vast majority of times, if you get in there, you numb up the toe, you cut out the corner of the nail, you do a straight-back, slant-back, it totally clears up. You don’t need antibiotics. You can then soak them afterward, but it clears up without needing antibiotics. If you get more proximal spread, spread to the inner phalangeal joint, spread around more than maybe one corner of the nail, I think most people feel comfortable using an antibiotic in these cases.
Maureen Jennings, DPM: I’ve seen it where the primary doctor has given an antibiotic and it still hasn’t gone away, because if you don’t take out that offending spicule, it’s not going to go.
Dr. Joseph: You, of course, need to remove the nail. We understand that in our profession but, unfortunately, a lot of other people don’t understand the need for that. Paronychias always heal up and they generally heal up really nicely—but even paronychias become an issue.
Exploring The Debate Over Doing A P&A For A Paronychia
Dr. Joseph: One of the issues that comes up a lot in legal circles is doing P&As in the presence of a paronychia. A few months ago, this question came up on one of the online list serves: Does anybody here do P&As in the presence of a paronychia? It was very evenly divided between two camps. You had people getting on there very powerfully saying, “You must never do P&As in the presence of a paronychia. That’s malpractice.” That’s a crock. That’s not malpractice and, in fact, what you have is another half of the profession getting on the list serve saying, “I’ve done this for 30 years. It saves the patient an extra surgical procedure.”
Phenol was the universal disinfectant. By definition, it kills all the organisms, it sterilizes the area. There’s no reason not to do a P&A in the presence of a paronychia. There are really two schools of thought on this issue, but I don’t think people should come down strongly one side or the other because a lot of docs are getting into trouble for this, one way or the other. So I think doing P&As in the presence of a paronychia is a personal choice. I don’t think there’s a real problem with it. Did I do it? No. But clearly there are two schools of thought.
What else becomes a problem when you do these nails? We think of this as an everyday procedure but if you take out that corner of the nail, what are you left with? A deep hole. The deep hole can drain for a little while, especially if you do the P&A afterward. It may drain for a couple of weeks.
After the patient leaves you, maybe he or she develops a cold or something for whatever reason. The patient’s primary doctor would treat the cold and the patient says, “Oh, by the way, look at my toe, it’s draining a little bit, it won’t stop oozing, and the podiatrist did this procedure on it.” The primary doctor looks at it, sees this deep hole and drainage coming out of it, and thinks the patient might have a bone infection.