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Drainage of an Acute Paronychia

48 citationsUpdated Oct 2026
Illustration: Drainage of an Acute Paronychia

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Acute paronychia involves infection of the nail fold, with management stratified by disease severity. Early felons and paronychia may be managed with antibiotics alone [4], whereas more advanced infections require incision and drainage [4]. Surgical drainage is the optimal treatment for any hand infection [39], and acute paronychial abscesses are generally treated operatively [2]. Definitive management requires a combination of surgical intervention, specifically incision and drainage, and appropriate antibiotic therapy tailored to the organism and infection severity [21]. Although there is no consensus on the best surgical technique for acute paronychial abscesses [2], large prospective studies are needed to identify the best treatment regimen for both acute and chronic paronychia [3].

Several surgical techniques are available depending on the clinical presentation. A simple technique of draining acute paronychia can be used as a drainage procedure and part of management [1]. The looped Penrose technique serves as a simple and less invasive alternative to traditional incision and drainage with packing [46], functioning as an effective single-episode intervention strategy for acute hand infections [46]. This method is particularly useful in patients with complex social challenges due to the ease of wound management and low rates of readmission and reoperation [46]. In cases of complicated paronychia, thorough excision is essential [9]. For severe paronychia, a heated wire can be used to burn holes through the nail to drain pus [5]. Additionally, the Mini-Winograd procedure combined with preoperative nail groove drainage is a strategy for treating pyogenic paronychia with granulation proliferation [26].

Postoperative care and complication rates are critical considerations. Antibiotics are not needed in the postoperative phase after excision of uncomplicated paronychia and felon in patients who are not at risk [7]. However, complicated paronychia and hand infections are more frequent than expected, occurring in 33% of cases [8], and are often iatrogenic [8]. In cases of complicated paronychia, empirical antibiotic therapy with amoxicillin–clavulanic acid is appropriate [9].

Anatomy & Pathophysiology

Etiology and Mechanisms

The pathogenesis of chronic paronychia involves specific microbial interactions that distinct from simple maceration. Sterile maceration of the posterior nail fold for three to six months does not produce the changes of chronic paronychia [13]. While the addition of hemolytic streptococci, Proteus mirabilis, Proteus morganii, E. coli, and Pseudomonas aeruginosa to occluded nail folds speeds maceration, it does not produce a final lesion significantly different from simple maceration [13]. In contrast, the retraction and rounding out phenomenon of the nail fold is repeatedly reproduced when C. albicans is added to the fold and occluded for 30 days [13]. Maceration of the posterior nail fold allows the passage of foreign material into the dermis of the fold, inciting a chronic inflammatory reaction [13]. The foreign material involved in chronic paronychia is postulated to be derived from organisms of the nail fold [13]. C. albicans may contribute to the development of chronic paronychia by destroying the epidermal barrier rather than by supplying the foreign material [13]. The amount of epidermal damage and the duration of lesions are much greater in chronic paronychia than in acute paronychia [13]. The basic mechanisms for paronychia in children are the same as those reported in adults [16]. Most hand infections are the result of minor wounds that have been neglected [38].

Anatomical Structures

The dorsal integument of the distal phalanx is a unique cutaneous unit characterized by the nail bed with its matrix [48]. Digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers [59]. Fibers dorsal to the digital neurovascular bundle are collectively called Cleland ligament [59], while fibers palmar to the digital neurovascular bundle are called Grayson ligament [59]. The location, course, caliber, and shape of the digital artery distal to the PIP joint is unique and must be appreciated in performing microvascular repair [73]. An exhaustive anatomic dissection of all veins of the finger distal to the proximal interphalangeal joint was performed on 67 cadaveric fingers, measuring over 3200 vein segments [66].

Pathophysiology and Complications

Hand infections are associated with a high rate of complications that are often difficult to manage [24]. The classic consequences of infection, even if mild, mainly include stiffness [99].

Classification

Chronic Paronychia: Chronic paronychia is classified as a variety of hand dermatitis caused by environmental exposure, rather than a type of onychomycosis [37]. The underlying cause is generally agreed to be prolonged exposure to (cold) water, which allows Candida and Pseudomonas species to act as opportunist pathogens [22]. Staphylococcus pyogenes and Candida albicans are frequently cultured from infected nail folds in this condition [32].

Pathogenic Mechanisms: The mechanisms of infection, trauma, and prolonged immersion of the hands in water are not sufficient to explain the chronic forms of paronychia [6]. Sterile maceration did not produce the changes of chronic paronychia when prolonged for three to six months [13]. However, the addition of C. albicans to occluded nail folds allowed researchers to repeatedly reproduce the retraction and rounding out phenomenon after 30 days [13].

Pediatric Presentation: Chronic paronychia in children differs from adults in sources of maceration, associated diseases, clinical appearances of the lesion, and patients' responses to symptoms [16].

Clinical Presentation

Acute paronychia manifests clinically with erythema, temperature elevation, oedema, and marked tenderness [65]. The condition is usually bacterial in origin [65]. It begins as a subcuticular or intracutaneous infection with exudate developing in a localized area [65]. The infection eventually spreads under the base of the fingernail, elevating it from the nail matrix and eventually from the nail bed [65]. Infection may follow the nail margin or extend beneath the nail to suppurate [65].

Chronic paronychia presents with less erythema than the acute form [65]. Inspection reveals a cushion-like thickening of the paronychial tissue [65]. Nail plates may be thickened and discoloured [65], and may exhibit pronounced transverse ridges [65]. The chronically infected nail eventually becomes distorted [65].

Rarely, paronychia infection penetrates more deeply into the finger, causing necrosis of the tendons [65]. Further extension along the sheaths may result from this deep penetration [65]. In rare instances, osteomyelitis may develop [65]. More advanced infections of the finger require incision and drainage [4].

Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms [31]. Herpetic whitlow is self-limiting and usually resolves within three weeks [15]. A patient with Kaposi's sarcoma in the hand presented with what appeared to be a chronic paronychia [12]. In a case of atypical chronic sterile paronychia in a patient with thromboangiitis obliterans, the condition evolved and eroded into the joint space [10]. The combination of persistent active inflammation, compromised vasculature, poor hand hygiene, poor healing, and reluctance to seek treatment may allow paronychia to evolve and erode into the joint space [10].

In a case of acute felon associated with paronychia, the finger pulp was tense and painful and varied from pale to pink with the patient's pulse [63]. Exploration revealed frank purulence with communication between the subungual abscess and the finger pulp [63]. All 10 fingernails developed draining subungual abscesses [63]. Nail dystrophy was characterized by onycholysis, nail pain, and subungual hemorrhage [63]. In a case of severe paronychia, burning holes through the nail with a heated wire to drain pus resulted in instant relief [5]. The patient returned to full duty by the fifth morning after treatment with a heated wire [5].

Investigations

Clinical Assessment: Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [44]. A careful physical examination is essential to direct care and future testing if indicated [40].

Laboratory: Diagnostic tests such as serum laboratory studies are useful in the determination of pathologic processes but can be expensive, time consuming, and often nonspecific [40]. Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism [31].

Plain Radiography: Early osteomyelitis of the bone can be detected long before the roentgenogram reveals evidences of destruction [90].

Treatment

Non-Operative

Early felons and paronychia may be managed with antibiotics alone, while more advanced infections require incision and drainage [4]. For chronic paronychia, fluconazole at 50 mg/day is both effective and safe [75]. Low-level laser therapy (LLLT) for chronic paronychia required on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint [14]. Chemical sealing of the proximal nail fold with cyanoacrylate glue results in the gap between the proximal nail fold and nail plate healing and filling up within 6–8 weeks [23]. Maceration dressings used alongside intravenous antibiotic treatment can improve the treatment course of patients with hand infections [64]. Patients using maceration dressings for hand infections had significantly shorter hospital lengths of stay compared to those treated with standard dressings [64]. These patients also had a significantly shorter duration of intravenous antibiotics before transition to oral antibiotics compared to those treated with standard dressings [64]. Furthermore, patients using maceration dressings for hand infections had a decreased need for formal operating room irrigation and debridement to obtain source control compared to those treated with standard dressings [64].

Operative

Indications: Acute paronychial abscesses are generally treated operatively, but there is no consensus on the best surgical technique [2]. Surgical debridement is indicated when purulence is present at the time of initial diagnosis or if the infection progresses during treatment with oral antibiotics [18]. Treatment of acute hand infections requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity [21]. In cases of complicated paronychia, empirical antibiotic therapy with amoxicillin–clavulanic acid is appropriate [9]. Aerobic and anaerobic cultures should be obtained when antimicrobial therapy is contemplated for serious paronychia in children [36].

Surgical Approach / Technique: A simple technique involving a specific drainage procedure can be used as part of the management of acute paronychia [1]. The Swiss Roll Technique is recommended for the treatment of both severe acute and chronic paronychia [27]. There are no contraindications for the Swiss Roll Technique [27]. Thorough excision is essential in cases of complicated paronychia [9]. The Mini-Winograd Procedure combined with preoperative nail groove drainage is a strategy for the treatment of pyogenic paronychia with granulation proliferation [26]. Eponychial marsupialization is an effective means of treating chronic paronychia [83]. The eponychial marsupialization procedure has been highly effective in curing chronic paronychia, a generally intractable condition [43]. The square flap technique provides an alternative treatment for chronic paronychia with good prognosis and optimal cosmetic results [11]. A single case of severe paronychia was treated by burning holes through the nail with a heated wire to drain pus, resulting in instant relief [5]. For herpetic whitlow, surgical intervention should be minimal and aim at decompression in the form of deroofing the vesicles [15]. Incision and drainage for herpetic whitlow with bacterial abscess resulted in no sign of adverse sequelae or recurrence of the herpes infection at 3 years' follow-up [17].

Complications and Prognosis: Complicated paronychia and hand infections are more frequent than expected, occurring in 33% of cases, and are often iatrogenic [8].

Complications

Infection: The complications associated with mycobacterial hand infections can be significant [25]. Persistent active inflammation, compromised vasculature, poor hand hygiene, poor healing, and reluctance to seek treatment may allow paronychia to evolve and erode into the joint space [10].

Recovery

Light activity (weeks): With prompt and appropriate care, most soft tissue hand infection patients can achieve full resolution of their infections [35]. The infection is self-limiting and usually resolves within three weeks, so surgical intervention should be minimal and aim at decompression in the form of deroofing the vesicles [15]. Treatment in all cases is nonsurgical; resolution is complete within 3 to 4 weeks [34]. The patient returned to full duty by the fifth morning following treatment for severe paronychia [5].

Other Considerations: The gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks, providing relief from chronic paronychia [23]. Chronic paronychia required on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint [14]. At 3 years' follow-up, there was no sign of adverse sequelae resulting from the incision and drainage and no recurrence of the herpes infection [17].

Key Evidence

  • [L4] It can thus be used as drainage procedure and part of management of acute paronychia. [1] (10.1097/01.bth.0000163575.00615.69)
  • [L5] While acute paronychial abscesses are generally treated operatively, there is no consensus on the best surgical technique. [2] (10.1016/j.jhsa.2011.11.021)
  • [L5] Large, prospective studies are needed to identify the best treatment regimen for acute and chronic paronychia. [3] (10.5435/jaaos-22-03-165)
  • [L5] The review provides a focused summary of management approaches, noting that early felons and paronychia may be managed with antibiotics alone, while more advanced infections require incision and drainage. [4] (10.1016/j.jemermed.2025.07.054)
  • [L5] The author reports a single case of severe paronychia treated by burning holes through the nail with a heated wire to drain pus, resulting in instant relief and the patient returning to full duty by the fifth morning. [5] (10.1136/bmj.2.4417.299-a)
  • [L4] The author describes the principal clinical characteristics of paronychia and reviews its pathogenesis, stressing the fact that the mechanisms of infection, trauma and prolonged immersion of the hands in water, are not sufficient to explain the chronic forms of the disease. [6] (10.1159/000255443)
  • [L2] The findings confirm that antibiotics are not needed in the postoperative phase after excision of uncomplicated paronychia and felon in patients who are not at risk. [7] (10.1016/j.hansur.2015.12.003)
  • [L4] Complicated paronychia and hand infections are more frequent than expected (33% of cases) and often iatrogenic. [8] (10.1016/j.hansur.2019.10.076)
  • [L4] In cases of complicated paronychia, thorough excision is essential and empirical antibiotic therapy with amoxicillin–clavulanic acid is appropriate. [9] (10.1016/j.hansur.2025.102235)
  • [L5] The combination of persistent, active inflammation, compromised vasculature, poor hand hygiene, poor healing and a reluctance to seek treatment may well have allowed the paronychia to evolve and erode into the joint space. [10] (10.1111/j.1440-0960.2012.00967.x)
  • [L4] This surgical technique can provide an alternative treatment for chronic paronychia, with good prognosis during follow up-period and optimal cosmetic results. [11] (10.1016/j.jaad.2016.02.1154)
  • [L5] The patient had what appeared to be a chronic paronychia. [12] (10.1016/s0363-5023(86)80151-4)
  • [L4] [13] (10.1001/archderm.1964.01590270141032)
  • [L4] Chronic paronychia required on average 20.4 ± 18.32 days of therapy to reach the treatment endpoint. [14] (10.5978/islsm.10.133)
  • [L5] The infection is self-limiting and usually resolves within three weeks, so surgical intervention should be minimal and aim at decompression in the form of deroofing the vesicles. [15] (10.1016/0266-7681(85)90037-3)
  • [L4] [16] (10.1177/000992286800700213)
  • [L5] At 3 years' follow-up, there was no sign of adverse sequelae resulting from the incision and drainage and no recurrence of the herpes infection. [17] (10.1016/s0363-5023(10)80117-0)
  • [L4] Surgical debridement is indicated when purulence is present at the time of initial diagnosis or if the infection progresses during treatment with oral antibiotics. [18] (10.1177/1558944718788666)
  • [L5] Treatment requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity. [21] (10.1016/j.jhsa.2014.03.031)
  • [L5] The underlying cause of chronic paronychia is generally agreed to be prolonged exposure to (cold) water, allowing Candida and Pseudomonas species to act as opportunist pathogens. [22] (10.1136/bmj.2.6200.1294-a)
  • [L4] The gap between the proximal nail fold and nail plate heals and fills up within 6–8 weeks, providing relief from chronic paronychia. [23] (10.25259/csdm_132_2023)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [24] (10.1016/j.hcl.2020.03.010)
  • [L4] The complications associated with mycobacterial hand infections can be significant. [25] (10.1177/1558944720940064)
  • [L4] In terms of aesthetic outcomes, recurrence, and postoperative rehabilitation, we believe our strategy is a valuable advancement in the treatment of pyogenic paronychia with granulation proliferation and warrants further adoption in clinical practice. [26] (10.1155/dth/7025119)
  • [L4] [27] (10.1097/bth.0b013e3181ec089e)
  • [L4] Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism. [31] (10.1016/j.jhsa.2025.09.023)
  • [L5] The paper reviews the aetiology and treatment of chronic paronychia, noting that Staphylococcus pyogenes and Candida albicans are frequently cultured from infected nail folds. [32] (10.1136/bmj.4.5730.257)
  • [L4] Treatment in all cases is nonsurgical; resolution is complete within 3 to 4 weeks. [34] (10.1016/s0363-5023(09)91128-5)
  • [L4] With prompt and appropriate care, most soft tissue hand infection patients can achieve full resolution of their infections. [35] (10.7717/peerj.513)
  • [L4] The authors recommend that aerobic and anaerobic cultures be obtained when antimicrobial therapy is contemplated for serious paronychia in children. [36] (10.1016/0002-9610(81)90082-9)
  • [L1] The results support the view that chronic paronychia is not a type of onychomycosis but a variety of hand dermatitis caused by environmental exposure. [37] (10.1067/mjd.2002.122191)
  • [L4] Most hand infections are the result of minor wounds that have been neglected. [38] (10.1016/j.ijid.2005.06.009)
  • [L4] Surgical drainage is the optimal treatment of any hand infection. [39] (10.1016/j.hansur.2020.12.011)
  • [L4] The authors state that the eponychial marsupialization procedure has been highly effective in curing chronic paronychia, a generally intractable condition. [43] (10.1097/00006534-197607000-00011)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [44] (10.1016/j.hcl.2020.03.002)
  • [L4] The looped Penrose technique is a simple and less invasive alternative to traditional incision and drainage with packing and serves as an effective single-episode intervention strategy for acute hand infections, particularly in patients with complex social challenges because of the ease of wound management and low rates of readmission and reoperation. [46] (10.1016/j.jhsa.2024.11.015)
  • [Case_report] [63] (10.1007/s11552-007-9029-3)
  • [L2] [64] (10.1177/1558944719852744)
  • [L4] [65] (10.1016/0266-7681(93)90063-l)
  • [L5] An exhaustive anatomic dissection of all veins of the finger distal to the proximal interphalangeal joint was performed on 67 cadaveric fingers, measuring over 3200 vein segments. [66] (10.1016/s0363-5023(10)80115-7)
  • [L5] The location, course, caliber, and shape of the digital artery distal to the PIP joint is unique and must be appreciated in performing microvascular repair. [73] (10.1016/s0363-5023(10)80114-5)
  • [L4] These results show that 50 mg/day fluconazole is both effective and safe in the management of chronic paronychia. [75] (10.3109/09546639909056029)
  • [L4] Eponychial marsupialization is an effective means of treating chronic paronychia. [83] (10.1016/s0363-5023(10)80118-2)
  • [L4] Early osteomyelitis of the bone can be detected long before the roentgenogram reveals evidences of destruction. [90] (10.1097/00000658-194001000-00013)
  • [L5] The classic consequences of infection (even if mild), mainly stiffness, can appear. [99] (10.1016/j.main.2015.07.004)

See Also

References

[1] DAREJD Simple Technique of Draining Acute Paronychia. Techniques in Hand & Upper Extremity Surgery. 2005. DOI: 10.1097/01.bth.0000163575.00615.69

[2] Acute Paronychia. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.021

[3] Acute and Chronic Paronychia of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2014. DOI: 10.5435/jaaos-22-03-165

[4] Management of Finger Felons and Paronychia: A Narrative Review. The Journal of Emergency Medicine. 2025. DOI: 10.1016/j.jemermed.2025.07.054

[5] Treatment of Severe Paronychia. BMJ. 1945. DOI: 10.1136/bmj.2.4417.299-a

[6] Pathogenesis and Treatment of Chronic Paronychia. Dermatologica. 2009. DOI: 10.1159/000255443

[7] Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients. Hand Surgery and Rehabilitation. 2016. DOI: 10.1016/j.hansur.2015.12.003

[8] Les panaris compliqués d’emblée : plus fréquents qu’attendus et souvent iatrogènes. Hand Surgery and Rehabilitation. 2019. DOI: 10.1016/j.hansur.2019.10.076

[9] Epidemiology and management of purulent paronychia: A bicentric study. Hand Surgery and Rehabilitation. 2025. DOI: 10.1016/j.hansur.2025.102235

[10] Atypical chronic sterile paronychia leading to tissue and joint space destruction in a patient with thromboangiitis obliterans. Australasian Journal of Dermatology. 2012. DOI: 10.1111/j.1440-0960.2012.00967.x

[11] Chronic paronychia treatment: Square flap technique. Journal of the American Academy of Dermatology. 2016. DOI: 10.1016/j.jaad.2016.02.1154

[12] Kaposi's sarcoma in the hand of an AIDS patient. The Journal of Hand Surgery. 1986. DOI: 10.1016/s0363-5023(86)80151-4

[13] Experimental Studies on Chronic Paronychia. Archives of Dermatology. 1964. DOI: 10.1001/archderm.1964.01590270141032

[14] TREATMENT OF NAIL DISORDERS WITH LLLT (2) CHRONIC PARONYCHIA AND INGROWN NAIL. LASER THERAPY. 1998. DOI: 10.5978/islsm.10.133

[15] An unusual hand infection in a child—remember herpes!. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1985. DOI: 10.1016/0266-7681(85)90037-3

[16] Chronic Paronychia in Children. Clinical Pediatrics. 1968. DOI: 10.1177/000992286800700213

[17] Herpetic whitlow with bacterial abscess. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80117-0

[18] Oral Antibiotics Are Effective for the Treatment of Hand Osteomyelitis in Children. HAND. 2018. DOI: 10.1177/1558944718788666

[21] Acute Hand Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.031

[22] Treatment of chronic paronychia. BMJ. 1979. DOI: 10.1136/bmj.2.6200.1294-a

[23] Chemical sealing of proximal nail fold with cyanoacrylate glue for accelerated regeneration of nail cuticle as a treatment of chronic paronychia. Cosmoderma. 2023. DOI: 10.25259/csdm_132_2023

[24] Complications of Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.010

[25] Mycobacterial Infections of the Hand. HAND. 2020. DOI: 10.1177/1558944720940064

[26] Mini‐Winograd Procedure and Preoperative Nail Groove Drainage for Pyogenic Paronychia With Granulation Tissue. Dermatologic Therapy. 2026. DOI: 10.1155/dth/7025119

[27] Swiss Roll Technique for Treatment of Paronychia. Techniques in Hand & Upper Extremity Surgery. 2011. DOI: 10.1097/bth.0b013e3181ec089e

[31] Atypical Hand Infections. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.09.023

[32] Problems of chronic paronychia.. BMJ. 1970. DOI: 10.1136/bmj.4.5730.257

[34] Pediatric herpetic hand infections. The Journal of Hand Surgery. 1990. DOI: 10.1016/s0363-5023(09)91128-5

[35] Hand infections: a retrospective analysis. PeerJ. 2014. DOI: 10.7717/peerj.513

[36] Bacteriologic study of paronychia in children. The American Journal of Surgery. 1981. DOI: 10.1016/0002-9610(81)90082-9

[37] Topical steroids versus systemic antifungals in the treatment of chronic paronychia: An open, randomized double-blind and double dummy study. Journal of the American Academy of Dermatology. 2002. DOI: 10.1067/mjd.2002.122191

[38] Epidemiology of bacterial hand infections. International Journal of Infectious Diseases. 2006. DOI: 10.1016/j.ijid.2005.06.009

[39] Advanced finger infection: more frequent than expected and mostly iatrogenic. Hand Surgery and Rehabilitation. 2021. DOI: 10.1016/j.hansur.2020.12.011

[40] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[43] SURGICAL CURE OF CHRONIC PARONYCHIA BY EPONYCHIAL MARSUPIALIZATION. Plastic and Reconstructive Surgery. 1976. DOI: 10.1097/00006534-197607000-00011

[44] Imaging and Laboratory Workup for Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.002

[46] Looped Penrose Drainages of Acute Hand Infections in Vulnerable Populations. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.11.015

[48] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.

[59] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[63] Acute Felon as a Complication of Systemic Paclitaxel Therapy: Case Report and Review of the Literature. HAND. 2007. DOI: 10.1007/s11552-007-9029-3

[64] The Clinical Utility of Maceration Dressings in the Treatment of Inpatient Hand Infections: An Evaluation of Treatment Outcomes Compared to Standard Care. HAND. 2019. DOI: 10.1177/1558944719852744

[65] Paronychia: a Mixed Infection. Journal of Hand Surgery. 1993. DOI: 10.1016/0266-7681(93)90063-l

[66] The distal venous anatomy of the finger. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80115-7

[73] Artery anatomy and tortuosity in the distal finger. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80114-5

[75] Fluconazole 50 mg/day therapy in the management of chronic paronychia. Journal of Dermatological Treatment. 1999. DOI: 10.3109/09546639909056029

[83] Eponychial marsupialization and nail removal for surgical treatment of chronic paronychia. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80118-2

[90] NEW INCISION FOR CLOSED SPACE INFECTION (FELON) INVOLVING DISTAL PHALANX OF FINGER. Annals of Surgery. 1940. DOI: 10.1097/00000658-194001000-00013

[99] Complications after microdermal piercing in the hand: Report of two cases. Chirurgie de la Main. 2015. DOI: 10.1016/j.main.2015.07.004

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Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.