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?