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.
So the primary doc sends the patient to the radiologist, who takes the X-ray. We all see distal phalanges all the time and they’re all choppy looking and if there’s inflammation, they look a little washed out. The radiologist looks at this and says, “Change is consistent with osteomyelitis. You better go see the orthopedic surgeon.” Well, the next thing you know, the patient sees the orthopedic surgeon who then looks at the X-ray report and says, “Osteomyelitis? Let’s lop off the toe.” So you’ve got podiatrists getting in trouble, being sued, for patients who have lost their toes because they’ve done a paronychia.
So something we do daily and love as a procedure can actually lead to problems. Even the most basic everyday community-acquired infection can cause problems. Then there’s the other question: How many people use antibiotics with a P&A? I mentioned that a little bit earlier. Some people will, some people won’t, some people wait until there’s more involvement, maybe a little proximal involvement.
Mark Kosinski, DPM: I’m just curious. What’s the rationale for the physicians who are vehemently opposed to the point of claiming malpractice for doing a P&A at the time of initial presentation?
Adam Landsman, DPM, PhD: If you have an abscess and there’s a high concentration of bacteria in that area, by potentially deepening and potentially introducing it more proximally, it can potentially facilitate the spread of that bacteria.
Dr. Joseph: When the surgery has been done to remove the nail, by sticking a swab with some chemical on it, are you really deepening the wound when that chemical is a universal disinfectant which is going to kill all the organisms that haven’t drained out?
Dr. Landsman: At least when I’m doing my I&Ds, I
typically don’t go all the way back to the root of the nail. I typically go back as far as I need to take the spicule out. All of us have done P&As and seen recurrence of spicules of nail. I have a 90 percent success rate, not a 100 percent success rate, which tells me our caustic chemical we’re inserting in there doesn’t make contact with every spot. So there is a potential for this deep wound to not be completely sterilized with that phenol.
Infection, Inflammation Or Degrees Of Infection?
Richard Pollak, DPM, MS: In my practice, I kind of agree with Warren. I feel most paronychias are inflammations rather than true infections. I look at them as more of a foreign body and I explain to patients it’s like stepping on a thorn. I can give the antibiotics for the next six months, but if I don’t take that thorn out of your foot, we’re not going to get you better.
I infrequently use antibiotics orally unless the patient requests the antibiotic or if he or she is diabetic, and that’s more from a medical/legal CYA approach. However, I don’t really see the need to use an oral antibiotic on a healthy person. I normally will do a phenol. I don’t even use alcohol anymore. I didn’t really see the reason for it. I’ll locally anesthetize the toe proximal block, go all the way back to the hyponychiam to the root, remove the nail, and I will do the phenol.
I think the reason for spiculization or recurrence in nails is poor homeostasis or the phenol becomes old. Some people use a bottle. It takes a long time to go through a bottle of phenol and perhaps it’s not as effective any more. I think that’s why you get the recurrences. I also think some of the other recurrences are in the more infected patients.
Dr. Joseph: Maybe there are degrees of infection. I know that one of the discussions that came up was how to treat a mild, localized paronychia that is more of a simple inflammation than an infection. Doing a P&A is certainly indicated in this case. However, I think most people, if they were treating a major abscess with proximal spread, would probably not go ahead and do a P&A.
Dr. Kosinski: I’ve cultured MRSA out of paronychias. Taking a thorough history to find out if the patient has risk factors for resistant Staph is very important. Using an antibiotic that’s not active against resistant Staph is like giving no antibiotic at all.
To Soak Or Not To Soak?
Dr. Pollak: Traditionally, we’ve all been taught to soak paronychias in Epsom salts and warm water for 15 minutes twice a day for three weeks and I’ve been doing that for many years. What I have noticed, though, on occasion when I’ve done a nail procedure with a bone surgery—which I try not to do but on a rare occasion you’ll do that—obviously, you’re not soaking that person’s foot. You’re just keeping that foot dry. I have found those P&A procedures heal up empirically quicker with less drainage, less inflammation.
Perhaps a little study could be done at one of the schools. Maybe 100 patients with a phenol procedure with a traditional soaking, and then 100 with just the phenol application and then perhaps the phenol and alcohol.
I just wondered if anyone else had any comment on the paronychia, the question of whether to soak or not to soak or is it podiatry folklore?
Dr. Joseph: I’ve always soaked them but if you get the old drawing action, who knows? I have a feeling we all pretty much soak them, except if they have diabetes. I’ve never soaked patients with diabetes.
Dr. Landsman: What’s your rationale, other than the fact that the ADA has an official statement against it?
Dr. Joseph: Pretty much the fact that the ADA has a statement against it. Everywhere it’s been written in big bold print: Never soak the foot in a patient with diabetes. Is there any science behind that idea? I don’t think so. In fact, I know it’s pretty controversial even within the diabetes community whether you should soak or not. I don’t soak ulcers in patients with diabetes. I do soak paronychias, unless the patients have diabetes.
Dr. Landsman: I’m sure you have used saline with the dry dressing for diabetic patients.
Dr. Joseph: Yes.
Dr. Landsman: How do you differentiate saline with the dry dressings from soaks, assuming that your objective is the same, to draw out the garbage?
Dr. Joseph: Because my saline with the dry dressing is in a specific location. There’s more control. I don’t have the patient sticking his or her foot in a basin of water, the same basin they maybe just washed some dishes in or soaked an ingrown toenail in before and you know they didn’t clean it out right. There’s the possibility of cross-contamination from organisms in an inner space getting into a wound, for instance, because they are now freely floating around in the water.
Usually if I’m giving patients saline soaks, they have a sterile bottle of saline. Sometimes I’ll tell them to mix up their own salt water, but they’re not just sticking with that. There’s not the concern of heat and tolerance. Some patients with diabetes stick their feet under a hot faucet waiting until the water gets to the right temperature but they’re so neuropathic, they can’t feel it so they end up with second-degree burns. So I think there’s a major difference between the dry dressings and soaking.
Dr. Landsman: The concerns you raised, with the exception of regulating the temperature, really can apply to anyone. Any wound has potential for contamination in the basin and the bacteria from between the toes, and yet the diabetics are always pulled aside and you say don’t soak the diabetic.