Five months ago, a teenager suffered an injured cuticle while trimming his toenail. Bacitracin and alcohol (recommended by a physician friend of the family) was unsuccessful. The lesion oozes and bleeds after the patient wears shoes, and the surrounding area is very tender and warm. What diagnosis and treatment should I consider?

Inflammation of the nail fold (acute paronychia) can occur following injury to the cuticle. Postinjury oozing and bleeding of the nail fold can also result from the subsequent development of an ingrown toenail (onychocryptosis) or granulation tissue (pyogenic granuloma). These conditions might require partial nail plate avulsion, removal of the vascular tissue lesion, or both. Incision and drainage may be necessary if abscess is present. Adjuvant topical care could include soaking in warm water and mupirocin (Bactroban) 2% ointment. Systemic antibiotic treatment is likely to be warranted as well. The initial choice of antimicrobial agent should cover Staphylococcus aureus. However, bacterial culture may be helpful to definitively identify the suspected organism(s) and guide subsequent management based on the susceptibilities of the isolated bacteria.
—Philip R. Cohen, MD