What Is The Best Way To Treat Paronychias?

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Roundtable Participants

Dr. Joseph is an Adjunct Associate Professor of Internal Medicine within the Section of Infectious Diseases at the Temple University School of Medicine. He is a Fellow of the Infectious Diseases Society of America.

Dr. Jennings is the Director of Clinical Research at the New York College of Podiatric Medicine. Dr. Landsman is the Director of Research, a Professor of Medicine and Surgery, and an Adjunct Professor of Biologic Sciences at the Dr. William A. Scholl College of Podiatric Medicine at Finch University.

Dr. Kosinski is a Professor in the Department of Medicine at the New York College of Podiatric Medicine. Dr. Pollak is a Clinical Assistant Professor in the Department of Orthopedics at the University of Texas Health Science Center.

“Clearly, there are two schools of thought on doing a P&A  in the presence of a paronychia.”
—Dr. Joseph
“I feel most
paronychias are inflammations rather than true infections.” 
—Dr. Pollak

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.

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