Nail infections are septic infections of the soft tissues around the finger (toe) nail, caused by bacteria that grow and multiply under the skin through a minimally invasive break in the skin next to the nail. In the fingers, it is most often caused by injuries such as puncture wounds, torn flesh spurs or deep nail trimming. In the toes, it is most often caused by ingrown nails or tight shoes, mostly in the bunions. Nail fungus is most often seen in adolescents or women. It can occur in the fingers or in the toes, but in the fingers it is often caused by a bad habit of gnawing on the fingers and in the toes it is often caused by secondary infection from ingrown nails. In the toes, it is often caused by ingrown nails or tight shoes, mostly in the thumb. The nail infection starts with mild pain and redness on one side of the nail, and then becomes more aggressive and pus spreads to the other side or under the nail, forming an abscess under the nail, where yellowish-white pus can be seen, separating the deep nail from the nail bed. On the side of the ingrown toenail there is often chronic hyperplasia of the flesh tooth tissue, which keeps the wound from healing for a long time. The proximal side of the nail (nail root) is closely attached to the skin, and the skin extends along both nails distally, forming a nail groove. A nail groove is an infection of the nail groove or its surrounding tissues. It is mostly caused by injuries such as tiny puncture wounds, contusions, barbs (reverse stripping) or cutting the nail too deeply, and the causative organism is mostly Staphylococcus aureus. Zhang Desheng, Department of General Surgery, Chifeng Second Hospital
The nail gouge can be divided into acute nail gouge, chronic nail gouge, purulent nail gouge, simple nail gouge, and ingrown nail gouge according to the cause and clinical manifestations.
1. Acute nail infection: Acute nail infection is mostly caused by Staphylococcus and Candida infections. These bacteria are present on the human skin and are generally not easily infected by the human body. They usually enter through the nail contour injury or chronic irritation (such as water and decontaminants) caused by epidermal breakage causing nail infection. Acute onychomycosis can spread rapidly to the entire nail groove or even form an abscess under the nail. The local pain is severe and pulsating, and it increases when the arm is lowered, so the patient often holds the hand in front of the chest. The inflamed finger beats painfully with the heartbeat, which means that the ten fingers are connected to the heart, and there is a distinct feeling of tenderness.
2. Chronic nail fungus: Mostly occurs when acute nail fungus is not treated in time or is re-infected, and the nail becomes uneven and pitted. The nail may show green, yellow or black signs of infection under the nail. Diabetic patients and those who work with hands often immersed in water, such as housewives, fishermen, cleaners, bartenders, and cooks, are prone to chronic nail infections.
3. Septic nail infection: Septic nail infection is a purulent inflammation caused by untimely treatment of acute nail infection. The nail groove is mildly red, painful, the small skin of the nail peels off, a small amount of pus flows from the nail groove, the edge of the nail and the nail groove becomes black, and can gradually produce nodular or myxoid protrusions of inflammatory granulation tissue, from time to time secrete pus, easy to bruise bleeding, part of the nail is damaged, the nail deformation shrinks, the nail has longitudinal ridges or transverse grooves, under the nail there is pus sneaking. In severe cases, the nail can be completely loosened and fall off.
4. Simple nail fungus: Most of the simple nail fungus is located in the first toe of the foot, one or two angles of the front of the toenail pierce deep into the nail groove and do not grow out, every 2 weeks to 1 month, the toe will have a feeling of swelling and pain, accidentally touched will have a sharp pain, the pain will disappear after cutting with a knife, but after a while it will appear again. If you walk for a long time or do not trim your toenails, your toes may become swollen and red, and there may even be oozing and granulation-like tissue in the nail grooves.
5. Ingrown toenail: Ingrown toenail is a type of nail infection caused by a toenail growing into the flesh. After more than 3 weeks of inflammation in the nail groove of the toe, it is considered to be due to an ingrown nail. Most often seen in the thumb, the laterally growing nail plate grows into the nail crease wall, causing pain and inflammation and, in severe cases, septic symptoms.
Consequences of untreated onychomycosis and ingrown nails.
(1) Nail infections and ingrown toenails do not heal on their own and always walk with a limp, which affects the image.
(2) The toenail will be seriously deformed, resulting in the destruction of the nail bed and eventually the nail will be missing.
(3) Repeated inflammation of the toenail can lead to an abscess under the nail, and in severe cases, osteomyelitis.
Therefore, it is important to treat nail infections in a timely manner.
There are several common causes.
1) The toenail is cut too short and the soft tissue next to it grows upwards because there is no toenail to cover it, as a result the toenail grows out and pierces the soft tissue. 2) Wearing unsuitable shoes. Unsuitable shoes, such as pointed shoes, are too narrow in the front, which will squeeze the soft tissue of the toe, and over time, will also form ingrown nails.
3. The toe has been traumatized. As a result of kicking a soccer ball, collision, smashing, etc., the toe is broken, affecting the nail bed or nail cells when the toenail will also appear deformed.
4. In addition, fungal infection and body fat are also triggering factors.
General conservative treatment for nail infection.
(1) Antibiotics
There are many types of antibiotics, such as intramuscular, intravenous and topical.
Advantages: Strong inhibitory effect on bacteria, with some anti-inflammatory and pain-relieving effect.
Disadvantages: It does not seem to work for ingrown toenails caused by physical toenail piercing.
(2) Anti-inflammatory and analgesic agents
Such as salicylic acid preparations, etc., there are oral, ointment, injection and other types.
Advantages: can reduce pain and swelling, suitable for use when pain is unbearable.
Disadvantages: ineffective in the treatment of ingrown nails, if used for a long time, the gastrointestinal tract stimulation is large, people suffering from gastrointestinal disease should be used with caution.
(3) Urea ointment
Advantages: It can soften the skin and toenail, which helps to correct it.
Disadvantages: It takes a long time to soften the toenail and is very troublesome. It is not effective when used alone, that is, even if the toenail is softened, it is difficult to cure the toenail deformation without using corrective means.
(4) Silver nitrate
Advantages: less pain during treatment, usually no anesthesia is needed, flattening of granulation tissue, and inhibition of pus and exudate.
Disadvantages: It is corrosive and can cause the skin and toenail to turn black, which can seriously affect the aesthetics. It is only useful for granulation tissue, and the correction of toenails is not very helpful.
(5) “Cotton cushion method” and “rubber tube cushion method”
Advantages: simple and convenient, can be handled by themselves.
Disadvantages: easy to fall off, insufficient filling force, poor results, easy to recur.
Instead of cotton, a drip tube is used to fill the nail sulcus and is glued with special glue.
(6) Traditional Chinese medicine therapy
Chinese herbal preparations are applied externally, herbal infusions, etc., or traditional pedicure techniques, etc.
Advantages: There are usually no side effects and it is more effective in eliminating inflammation.
Disadvantages: the effect of cure needs to be determined according to the personal experience of the physician, there is no uniform standard.
(7) Surgical treatment
Not all patients with nail infection are suitable for incision and drainage. Clinically, nail infection with pus accumulation should be incised and drained. Pre-operative preparation.
1.Rational selection of antibiotics according to the condition.
2. For patients with severe hand infection and weakened general condition, attention should be paid to improving general condition and body resistance.
3. When a deeper abscess is incised in the hand, it is advisable to control hemostasis with a tourniquet to make the surgical field clear and ensure surgical safety.
[Anesthesia]
1. For purulent dactylitis with incision and drainage or nail extraction with pus accumulation under the nail, anesthesia with nerve block at the root of the finger is generally used. No epinephrine should be added to the anesthetic to avoid spasm of small arteries, which may cause obstruction of blood flow to the fingers.
2. In the case of palmar interstitial abscess, septic tenosynovitis or bursitis of the hand with incision and drainage, brachial plexus nerve or wrist nerve block anesthesia is used; ketamine intravenous anesthesia can also be used.
[Surgical procedure]
A longitudinal incision is made along the nail root angle on the side of the lesion. In the case of total nail fungus, a longitudinal incision is made on each side, with the proximal end not exceeding the base of the nail bed. A sharp separation is made with a sharp-edged knife inserted between the nail root and the skin, and the flap is turned upward to release the pus and drainage by placing a gelatinous skin piece [Figure 1]. If there is pus accumulation under the nail, the nail should be removed and the pus drained while the nail is being drained, covered with petroleum jelly gauze and then bandaged. In cases of pus accumulation under the nail root only, partial nail excision and drainage can be performed by picking up the nail root and cutting it off. Care should be taken to cut out all the nail corners to avoid residual healing.
[Postoperative treatment]
1. After the hand infection is cut and drained, careful attention should be paid to changing the medication. First soak the wound with 1:5000 potassium permanganate solution, ask the patient to gently move the affected hand or finger, wash the wound with sterile cotton to facilitate the drainage of residual pus in the pus cavity, then dry the skin of the affected hand with dry gauze and disinfect it with alcohol, and dress it after drainage with gum skin sheet or Vaseline gauze strip.
2. Generally, the drainage strips can be removed 3 to 5 days after surgery. After the redness and swelling have subsided and the pain has been relieved, the functional exercise of the fingers should be started in order to avoid tendon adhesions and scar contractures that may cause dysfunction.