Staphylococcus aureus [MRSA]) and Streptococcus pyogenes Infection secondary to oral flora needs to be considered in children who suck their fingers Chronic paronychia presents similarly, although symptoms must be present for a minimum of weeks These are less common in children, but can be seen in patients repeatedly exposed to water or moist environments and those with underlying chronic dermatologic conditions Eventually, the nail may become thickened and discolored Candida albicans is the most frequent organism seen with chronic paronychia Treatment of a simple eponychia involves frequent warm soaks and attention to local hygiene Topical antibacterial ointments may hasten resolution Treatment of an acute paronychia is incision and drainage (Chapter 130 Procedures ) If an onychia has formed, removal of the proximal portion of nail overlying the abscess is essential to ensure adequate drainage and prevent destruction of the germinal matrix When an onychia forms under the anterolateral aspect of a nail, treatment consists of elevation and excision of the overlying portion of the nail While there is limited evidence for oral antibiotic treatment after incision and drainage, this practice remains common If the infection is due to finger biting or sucking, antibiotics providing coverage against anaerobes in addition to S aureus and S pyogenes should be considered Systemic antimicrobial therapy is indicated for patients with associated lymphangitis Coverage for MRSA should be considered if there is clinical suspicion, a high rate in the community, or the if infection is not improving on prior therapy Treatment of chronic paronychia consists of topical steroids and/or antifungal agents FIGURE 120.1 Paronychia of the finger (Reprinted with permission from Salimpour RR, Salimpour P, Salimpour P Photographic Atlas of Pediatric Disorders and Diagnosis 1st ed Philadelphia, PA: Lippincott Williams & Wilkins; 2013.) Herpetic Whitlow Herpetic whitlow , a herpes simplex virus (HSV) infection of the fingers, is sometimes mistaken for a paronychia and is the major differential diagnostic consideration Clinically, this lesion is characterized by the appearance of multiple, painful, thick-walled vesicles on erythematous bases most commonly located overlying the pulp space of the digits but can also occur around the nail folds and lateral aspects of the digit During the ensuing few days, vesicles begin to coalesce and their contents become pustular at which point it can be confused for a paronychia ( Fig 120.2 ) Subsequently, ulceration and crusting occur Most cases occur in children younger than years The process initially results from inoculation of HSV into a small break in the skin Sources of HSV inoculation include finger sucking in children with concurrent herpes gingivostomatitis or by parents with herpes labialis With primary infection, fever and regional adenopathy are often seen With recurrences, these findings are usually absent Unlike paronychia, Gram stain and culture of pustular fluid is negative for bacteria Testing the lesion for HSV is warranted Direct immunofluorescence assay (DFA) and polymerase chain reaction (PCR) are used most commonly When available, a Tzanck smear showing multinucleated giant cells can confirm the diagnosis in real-time, although such testing is less frequently performed A positive HSV culture can be diagnostic when other tests are negative or equivocal FIGURE 120.2 Herpetic whitlow (Reprinted with permission from Fleisher GR, Ludwig W, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Herpetic whitlow is usually self-limited However, oral acyclovir may be given in the first few days of the infection to shorten the course For the immunocompromised patient, parenteral acyclovir should be considered to prevent dissemination Herpetic whitlow can also be superinfected with bacteria in which case appropriate antibiotic therapy is indicated Felon A felon is a deep infection of the distal pulp space of the fingertip Felons are caused by introduction of bacteria into the pulp space, usually by punctures (which may be trivial) or splinters Causative organisms are similar to those found in eponychial infections A felon typically presents as an exquisitely tender and throbbing fingertip that is swollen, tense, warm, and erythematous Fluctuance may only be appreciated during later stages Felon usually evolves relatively slowly, beginning with mild pain and minimal swelling that progress over days This slow progression is in part caused by the anatomy of the pulp, which consists of multiple closed spaces formed by fibrous septae that connect the volar skin to the periosteum of the distal phalanx Infection is often initially contained within these small compartments With progression of infection, increased pressure may cause local ischemia Complications of felon include osteomyelitis, flexor tenosynovitis, and septic arthritis of the distal interphalangeal (DIP) joint Because the deep septal attachments are distal to the DIP joint and flexor tendon sheath, there is less risk of spread to these structures Treatment of a felon consists of incision, blunt dissection, and drainage Digital blocks are favored for analgesia A longitudinal incision over the area of maximal tension or fluctuance is the procedure of choice If swelling is greatest laterally, an incision along the ulnar surface of the second through fourth digit or radial side of pinky or thumb may be preferred Care should be taken to extend the incision past the DIP joint to prevent formation of a flexion contracture (see Chapter 130 Procedures ) After drainage, a course of oral antibiotics is indicated Close follow-up is essential to monitor for complications A hand specialist should be consulted for patients presenting with fever, lymphangitis, or evidence of osteomyelitis for admission, parenteral antibiotics, and definitive care Subungual Hematoma A subungual hematoma is a collection of blood located under a nail that arises after trauma to the nail bed, typically due to a crush injury Because this mechanism is also a common cause of phalangeal fractures, radiographs are often indicated Patients experience throbbing pain that worsens as more blood collects and pressure increases If the subungual hematoma involves more than 50% of a ... Herpetic whitlow (Reprinted with permission from Fleisher GR, Ludwig W, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) Herpetic whitlow is... finger (Reprinted with permission from Salimpour RR, Salimpour P, Salimpour P Photographic Atlas of Pediatric Disorders and Diagnosis 1st ed Philadelphia, PA: Lippincott Williams & Wilkins; 2013.)