Paronychia

Updated: Jun 06, 2016

Author: Elizabeth M Billingsley, MD; Chief Editor: William D James, MD

Practice Essentials
Paronychia is a soft tissue infection around a fingernail that begins as cellulitis but that
may progress to a definite abscess. [1] The 2 types of paronychia are as follows[2] :
Acute paronychia - Painful and purulent condition; most frequently caused by
staphylococci
Chronic paronychia - Usually caused by a fungal infection
The image below depicts paronychia.

Classic presentation of
paronychia, with erythema and pus surrounding the nail bed. In this case, the
paronychia was due to infection after a hangnail was removed.

Signs and symptoms

Physical findings in acute paronychia include the following:
The affected area often appears erythematous and swollen
In more advanced cases, pus may collect under the skin of the lateral fold
If untreated, the infection can extend into the eponychium, in which case it is called
eponychia
Further extension of the infection can lead to the involvement of both lateral folds as it
tracks under the nail sulcus; this progression is called a runaround infection
Physical findings in chronic paronychia include the following:
Swollen, erythematous, and tender nail folds without fluctuance are characteristic
of chronic paronychia
Eventually, the nail plates become thickened and discolored, with pronounced
transverse ridges
The cuticles and nail folds may separate from the nail plate, forming a space for
the invasion of various microorganisms
Diagnosis
The diagnosis of paronychia is based primarily on patient history and physical
examination. Some laboratory studies, however, can be useful. These include the
following:
Gram staining and/or culture - To help identify a bacterial cause of fluctuant
paronychia
Potassium hydroxide (KOH) 5% smears - To help diagnose fluctuant paronychia
caused by a candidal infection
Tzanck smears - If herpetic whitlow is suspected
See Workup for more detail.

Management
Treatment strategies for paronychia include the following:
If soft tissue swelling is present without fluctuance, the infection may resolve with
warm soaks 3-4 times daily [1, 3, 4]
Patients with extensive surrounding cellulitis or with a history of diabetes,
peripheral vascular disease, or an immunocompromised state may benefit from a
short course of antibiotics [5, 6]
If an abscess has developed, incision and drainage must be performed
Background
Paronychia is a soft tissue infection around a fingernail. More specifically, it is a
superficial infection of epithelium lateral to the nail plate that begins as cellulitis but that
may progress to a definite abscess. [1] The 2 forms of paronychia, acute and chronic,
usually differ in etiology, infectious agent, and treatment and are often considered
separate entities. [2]
The acute infection, which is painful and purulent, is most frequently caused by
staphylococci, although it commonly has mixed aerobic and anaerobic flora. [7] The
patient's condition and discomfort are markedly improved by a simple drainage
procedure. Chronic paronychial infections are usually fungal, rather than bacterial, in
nature (see the images below).
Classic presentation of paronychia, with erythema and pus surrounding the nail bed. In
this case, the paronychia was due to infection after a hangnail was removed.

In this case of paronychia, no pus or fluctuance is involved in the nail bed itself.
Typical appearance of paronychia.

Epidemiology
Paronychia is the most common hand infection in the United States, representing 35%
of these disorders. [3] The infection is more common in women than in men, with a
female-to-male ratio of 3:1.
Quality of life
A study by Belyayeva et al indicated that certain nail disorders, including paronychia,
can have a particularly high impact on quality of life. Using responses to a questionnaire
from 1063 patients with disorders of the fingernails and/or toenails, the investigators
found that the effect on quality of life was greatest in patients with nail problems
resulting from trauma, infections (including onychomycosis and paronychia), structural
abnormalities, and inflammatory diseases (including psoriasis). Quality of life was
particularly reduced in women, patients aged 60-79 years, and persons with multiple
nail involvement. [8]
According to the report, the results suggest that quality of life is influenced more by the
effect of a nail disease on the appearance of the nail than it is by the actual severity of
the disease.
Anatomy
The nail organ is an integral component of the digital tip. It is a highly versatile tool that
protects the fingertip, contributes to tactile sensation by acting as a counterforce to the
fingertip pad, and aids in peripheral thermoregulation via glomus bodies in the nail bed
and matrix. Because of its form and functionality, abnormalities of the nail unit result in
functional and cosmetic issues.
The anatomy of the nail complex is shown in the image below. The nail is longitudinally
flanked by 2 lateral folds, or perionychium. Proximally, it is covered by the eponychium.
Distal to the perionychium, the region immediately beneath the free edge of the nail is
the hyponychium. The hyponychium serves as a tough physical barrier that resists
bacterial infection.

Depicted are the nail fold (A), dorsal roof (B), ventral floor (C), nail wall (D),
perionychium (E), lunula (F), nail bed (G), germinal matrix (H), sterile matrix (I), nail
plate (J), hyponychium (K), distal groove (L), fascial septa (M), fat pad (N), distal
interphalangeal joint (O), and extensor tendon insertion (P).

Nail plate and bed

The nail, or nail plate, lies immediately on top of the nail bed, which consists of the
following 2 portions, which are involved in the production, migration, and maintenance
of the nail:
Proximal portion - Called the germinal matrix; contains active cells that are
responsible for generating new nail; damage to the germinal matrix results in
malformed nails
Distal portion - Called the sterile matrix; adds thickness, bulk, and strength to the
nail
The white, crescent-shaped opacity at the proximal end of the nail is the lunula, which is
the visible portion of the germinal matrix. The whiteness of the lunula is due to the poor
vascularity of the germinal matrix.
Nail fold
The nail arises from a mild proximal depression called the nail fold. The nail divides the
nail fold into 2 components: the dorsal roof and the ventral floor, both of which contain
germinal matrices. The skin overlying the nail fold is called the nail wall.
Vascular system
The nail bed receives its blood supply from the 2 terminal branches of the volar digital
artery. A fine network in the proximal nail bed and in the skin proximal to the nail fold of
the finger provides venous drainage. Lymphatic drainage follows a course similar to that
of the venous network. The lymphatic network is dense in the nail bed, especially in the
hyponychium. Innervation is derived from the trifurcation of the dorsal branch of the
volar digital nerve. One branch goes to the nail fold, one to the pulp, and one to the
distal tip of the finger.

Pathophysiology and Etiology

Paronychia, whether acute or chronic, results from a breakdown of the protective barrier
between the nail and the nail fold. The occurrence of cracks, fissures, or trauma
allowing organisms to enter the moist nail crevice leads to bacterial or fungal (yeast or
mold) colonization of the area. [9] Early in the course of this disease process (< 24 h),
cellulitis alone may be present. An abscess can form if the infection does not resolve
quickly.
Acute paronychia
Acute paronychia usually results from a traumatic event, however minor, that breaks
down the physical barrier between the nail bed and the nail; this disruption allows the
infiltration of infectious organisms. (See the image below.)

Paronychial erythema and edema with associated pustule. This suggests a bacterial
etiology.
Acute paronychia can result from seemingly innocuous conditions, such as hangnails,
or from activities such as nail biting, finger sucking, manicuring, or artificial nail
placement. Causative organisms include the following [10] :
Staphylococcus aureus - The most common infecting organism
Streptococcus species
Pseudomonas species
Gram-negative bacteria
Anaerobic bacteria
Fusarium species [11]

Chronic paronychia
Chronic paronychia is caused primarily by the yeast fungus Candida albicans. [12]Other,
rare causes of chronic paronychia include the following:
Bacterial, mycobacterial, or viral infection
Metastatic cancer
Subungual melanoma
Squamous cell carcinoma
Raynaud disease
Therefore, benign and malignant neoplasms should always be excluded when chronic
paronychia does not respond to conventional treatment.
Chronic paronychia most often occurs in persons whose hands are repeatedly exposed
to moist environments or in those who have prolonged and repeated contact with
irritants such as mild acids, mild alkalis, or other chemicals. People who are most
susceptible include housekeepers, dishwashers, bartenders, florists, bakers, and
swimmers. In addition, individuals who are immunocompromised, such as those with
human immunodeficiency virus (HIV) infection or those undergoing steroid therapy, are
predisposed to paronychia.
Other conditions associated with abnormalities of the nail fold that predispose
individuals to chronic paronychia include psoriasis, mucocutaneous candidiasis, and
drug toxicity from medications such as retinoids, epidermal growth factor receptor
inhibitors (cetuximab), and protease inhibitors. [13, 14] Of particular interest is the
antiretroviral drug indinavir, which induces retinoidlike effects and remains the most
frequent cause of chronic paronychia in patients with HIV disease.
Pemphigus vulgaris
Acute or chronic paronychia may also occur as a manifestation of other diseases, such
as pemphigus vulgaris. Although nail involvement in pemphigus vulgaris is rare, it can
be severe, involving multiple digits and hemorrhage.
Prognosis
If treated promptly, paronychia usually has a good prognosis, but it potentially can result
in a more serious infection, such as septic tenosynovitis, osteomyelitis, [15] or, by
spreading to the pulp space of the finger, a felon. Such infections develop more readily
in patients who are immunosuppressed or in those whose condition has been
mistreated or neglected. Secondary ridging, thickening, and discoloration of the nail can
also occur, as may nail loss. Occasionally, patients suffer systemic infection from
hematogenous extension. [16]

Patient Education
Instruct individuals to avoid any trauma to the fingernails and to avoid nail biting and
finger sucking. Educate patients who work with their hands in a moist environment that
such exposure predisposes them to infections. Inform patients that treatment is unlikely
to be successful if their exposure to a moist or wet environment is not changed. Explain
to patients who are immunocompromised that they must remain vigilant against any
minor trauma to the fingertips and nails.

Clinical Presentation
History
The patient's history is crucial in determining the possibility of systemic conditions and
risk factors that may predispose an individual to paronychia. [13, 17, 18, 19, 20, 21]
These may include the following:
Diabetes mellitus [22]
Obesity
Hyperhidrosis
Immunologic defects
Polyendocrinopathy
Drug-induced immunosuppression
Retroviral use - Indinavir and lamivudine, in particular, are thought to be associated
with an increased incidence of paronychia formation [23, 24]
Patients may give a history of the following [9, 25] :
Nail biting
Finger sucking
Trivial finger trauma
Finger exposure to chemical irritants
Use of acrylic nails or nail glue
Sculpted nails
Frequent hand immersion in water
Also query patients about the duration of symptoms and a history of nail infections and
previous treatment.
Because paronychia has been known to initiate from malignant lesions, any history of
prior malignancy or a pigmented, irregular appearance of surrounding tissue should
result in appropriate suspicion and referral for biopsy.
Painless swelling or severe swelling that radiates requires an expanded differential
diagnosis. [26] Painless swelling lateral to the nail plate in a patient with osteoarthritis
should prompt investigation for a mucous cyst.
Acute paronychia
The patient is usually otherwise healthy but complains of pain, tenderness, and swelling
in one of the lateral folds of the nail.
Chronic paronychia
Generally, patients report symptoms lasting 6 weeks or longer. Inflammation, pain, and
swelling may occur episodically, often after an exposure to water or a moist
environment.
Chronic and recurrent paronychial infections should be scrutinized to rule out
malignancy or fungal infection. [27, 28, 29]

Physical Examination
Acute paronychia
Physical findings in acute paronychia include the following:
The affected area often appears erythematous and swollen
In more advanced cases, pus may collect under the skin of the lateral fold
If untreated, the infection can extend into the eponychium, in which case it is called
eponychia
Further extension of the infection can lead to the involvement of both lateral folds
as it tracks under the nail sulcus; this progression is called a runaround infection
In severe cases, the infection may track proximally under the skin of the finger and
volarly to produce a concomitant felon. The fulminant purulence of the nail bed may
generate enough pressure to lift the nail off the nail bed.
Chronic paronychia
Physical findings in chronic paronychia include the following:
Swollen, erythematous, and tender nail folds without fluctuance are characteristic
of chronic paronychia
Eventually, the nail plates become thickened and discolored, with pronounced
transverse ridges
The cuticles and nail folds may separate from the nail plate, forming a space for
the invasion of various microorganisms

Additional considerations
Other signs to look for in a physical examination include the following:
Look for signs of a herpetic whitlow, such as vesicles on an erythematous base
Green coloration of the nail may suggest Pseudomonas species infection
Hypertrophy of the nail plate may be a clue to fungal infection
Constant severe pain with nail plate elevation, bluish discoloration of the nail plate,
and blurring of the lunula suggest the presence of a glomus tumor.
The digital pressure test can be used to detect the presence of an abscess. Pressure is
applied to the palmar surface of the distal finger; if an abscess is present, the area of
the abscess will blanch with palmar pressure. [30]

Differential Diagnoses
Diagnostic Considerations
Conditions to consider in the differential diagnosis of paronychia include the following:
Candidiasis
Dyshidrotic eczema
Felon
Hand infections
Herpetic Whitlow
Psoriasis
Bowen disease [31]
Kaposi sarcoma
Malignant melanoma
Pemphigus vulgaris [32, 33]
Pyogenic granuloma
Reactive arthritis
Splinters, foreign body
Mucous cyst
Subungual fibroma
Glomus tumor
Blastomycosis
Herpetic whitlow is a viral infection of the pulp of the fingertip and the perionychium that
can often be confused with the more common acute bacterial paronychia. Clear vesicles
that are grouped on an erythematous base are characteristic of herpetic whitlow.
Herpes simplex virus 1 causes approximately 60% of cases of herpetic whitlow, and
herpes simplex virus 2 causes the remaining 40% of cases.
Malignancies, such as melanoma and squamous cell carcinoma, or lesions, such as
chancres, granulomas, warts, or cysts, can occasionally mimic a paronychia. [34, 35]
Differential Diagnoses
Allergic Contact Dermatitis
Cellulitis
Chronic Mucocutaneous Candidiasis
Cutaneous Candidiasis
Cutaneous Manifestations of HIV
Cutaneous Squamous Cell Carcinoma
Dermatologic Manifestations of Herpes Simplex
Irritant Contact Dermatitis
Mucosal Candidiasis
Nail Cosmetics
Onycholysis
Onychomycosis
Pemphigus Vulgaris
Workup
Approach Considerations
The diagnosis of paronychia is based primarily on patient history and physical
examination. Some laboratory studies, however, can be useful.
Fluctuant paronychia usually results from bacterial infection; therefore, routine Gram
staining and culture can help in identifying the causative organism.
Potassium hydroxide (KOH) 5% smears may be helpful in diagnosing fluctuant
paronychia if Gram staining results are negative or if candidal infection is suspected, as
in chronic paronychia. If Gram staining results are positive, the KOH preparation may
demonstrate pseudomycelia and clusters of grapelike yeast cells. KOH wet mounts from
scrapings or discharge may show hyphae.
Tzanck smears may be performed if herpetic whitlow is suspected. Smears should be
performed by using base scrapings of an unroofed vesicle. The presence of
multinucleated giant cells, often with visible viral inclusions, indicates a positive result.
Imaging studies
Although imaging studies are not routinely necessary with paronychia, obtain a plain
film radiograph of the fingertip if osteomyelitis is suspected because of recurrent
infection, elevated erythrocyte sedimentation rate (ESR), or presence of risk factors for
osteomyelitis.
A radiograph can also be obtained if a foreign body is suspected or the patient has a
history of recent finger trauma.

Treatment & Management

Approach Considerations
The treatment of choice depends on the extent of the infection. If diagnosed early, acute
paronychia without obvious abscess can be treated nonsurgically. If soft tissue swelling
is present without fluctuance, the infection may resolve with warm soaks 3-4 times
daily. [1, 3, 4]
Patients with extensive surrounding cellulitis or with a history of diabetes, peripheral
vascular disease, or an immunocompromised state may benefit from a short course of
antibiotics. An antistaphylococcal penicillin or first-generation cephalosporin is generally
effective; clindamycin and amoxicillin-clavulanate are also appropriate. [5, 6]
If an abscess has developed, however, incision and drainage must be performed.
Surgical debridement may be required if fulminant infection is present. [36, 37]
Herpetic whitlow and paronychia must be distinguished because the treatments are
drastically different. Misdiagnosis and mistreatment may do more harm than good.
Once herpetic whitlow is ruled out, one must determine whether the paronychia is acute
or chronic and then treat it accordingly. [38]
Inpatient care
Admission for paronychia is rarely required unless associated with a significant cellulitis,
tendonitis, or deep space infection of the hand requiring intravenous antibiotics.
Consultations
It is necessary to consult a hand surgeon if cellulitis, deep space infection, glomus
tumor, mucous cyst, or osteomyelitis is suspected.
Long-term monitoring
Patients with recurring or chronic paronychia require frequent follow-up monitoring to
prevent possible superinfections or deep-seated infections.
Pharmacologic and Other Noninvasive Treatment
Acute paronychia
Warm water soaks of the affected finger 3-4 times per day until symptoms resolve are
helpful.
Oral antibiotics with gram-positive coverage against S aureus, such as amoxicillin and
clavulanic acid (Augmentin), clindamycin (Cleocin), or or cephalexin, are usually
administered concomitantly with warm water soaks. (Although antibiotics are commonly
prescribed, [1] most patients do not require antibiotics for a simple paronychia.)
Cleocin and Augmentin also have anaerobic activity; therefore, they are useful in
treating patients with paronychia due to oral anaerobes contracted through nail biting or
finger sucking. Cleocin should be used instead of Augmentin in patients who are allergic
to penicillin.
If the paronychia does not resolve or if it progresses to an abscess, it should be drained
promptly.
Chronic paronychia
The initial treatment of chronic paronychia consists of the avoidance of inciting factors
such as exposure to moist environments or skin irritants. Keeping the affected lesion dry
is essential for proper recovery. Choice of footgear may also be considered.
Any manipulation of the nail, such as manicuring, finger sucking, or attempting to incise
and drain the lesion, should be avoided; these manipulations may lead to secondary
bacterial infections.
Mild cases of chronic paronychia may be treated with warm soaks, followed by
completely drying the digit. The initial medical treatment consists of the application of
topical antifungal agents. Topical miconazole may be used as the initial agent. Oral
ketoconazole or fluconazole may be added in more severe cases.
Patients with diabetes and those who are immunocompromised need more aggressive
treatment because the response to therapy is slower in these patients than in others.
In cases induced by retinoids or protease inhibitors, the paronychia usually resolves if
the medication is discontinued.
Drainage
If paronychia does not resolve despite best medical efforts, surgical intervention may be
indicated. Also, if an abscess has developed, incision and drainage must be performed
(see the image below). Surgical debridement may be required if fulminant infection is
present.
 Paronychia incision and drainage.

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Acute paronychia
No-incision technique
Less-advanced paronychial abscesses can be drained simply by gently elevating the
eponychial fold from the nail by using a small blunt instrument such as a metal probe or
an elevator (see the image below). This separation is performed at the junction of the
perionychium and the eponychium and extends proximally enough to permit
visualization of the proximal nail edge. Then, the proximal third of the nail can be
excised with scissors and the pus evacuated.
 Simple acute paronychia can be drained by
elevating the eponychial fold from the nail with a small blunt instrument such as a metal
probe or elevator.

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This technique does not require an incision into the matrix. Often, no excision of any
tissues is made, because only blunt dissection and separation are needed to evacuate
the pus from the paronychia.
The wound should be well irrigated with isotonic sodium chloride solution, and plain
gauze packing should be inserted under the fold to keep the cavity open and allow
drainage.
The patient should receive oral antibiotics for 5-7 days. The packing is removed after 2
days, and warm sodium chloride solution soaks are begun.
Simple incision technique
The most simple and, often, least painful incision can be made without anesthesia,
using only an 18-gauge needle. The technique is performed as follows:
The needle is positioned bevel up and laid horizontally on the nail surface; it is
inserted at the lateral nail fold where it meets the nail itself, at the point of
maximum fluctuance
The skin of the nail fold is lifted, releasing pus from the paronychia cavity
A gentle side-to-side motion may then be used to increase the size of the incision
made by the needle, improving drainage; since the area incised is made up mostly
of necrotic tissue, this is often painless
Gentle pressure can be placed on the external skin to express any remaining pus
from the paronychia
The cavity can then be irrigated with saline
 A small piece of 1/4-in gauze or iodoform tape can be inserted into the paronychia
cavity for continued drainage. The wound is subsequently covered with a sterile
bandage.
Single- and double-incision techniques
If the paronychia is more advanced, it may need to be incised and drained. A digital
anesthetic block is usually necessary. If an anesthetic agent is used, it should consist of
1% lidocaine (Xylocaine). [4, 39] The local injection of the anesthetic agent into the
paronychia or the wound is often inadequate and more painful than the administration of
drugs of a digital block.
If the paronychia involves only 1 lateral fold of the finger, a single longitudinal incision
should be placed with either a number-11 or number-15 blade directed away from the
nail fold to prevent proximal injury and a subsequent nail growth abnormality. If both
lateral folds of the finger are involved, incisions may be made on both sides of the nail,
extending proximally to the base of the nail.
The next steps are as follows (see the images below):
After the single or double incision is made, the entire eponychial fold is elevated to
expose the base of the nail and drain the pus
The proximal third of the nail is removed by using the method described for the no-
incision technique
After the abscess is drained, the pocket should be well irrigated with isotonic
sodium chloride solution, packed with plain packing, and dressed
The patient should receive oral antibiotics for 5-7 days
The dressing and packing are removed in approximately 2 days, and the affected
finger is treated with warm soaks for 10-15 minutes 3-4 times per day

Wound opened with a small incision using a number-11 blade scalpel.

The wound can be explored with a blunt probe, clamps, or the blunt end of a cotton
swab.

Ensure that all loculations are broken up and that as much pus as possible is
evacuated.
 Prior to packing or dressing the wound, irrigate the wound with normal saline under
pressure, using a splash guard, eye protection, or both.

The wound can be covered with antibiotic ointment or petroleum jelly to prevent
bandage adhesion.

Chronic paronychia
The most common surgical technique used to treat chronic paronychia is called
eponychial marsupialization.
In this technique, the affected digit is first anesthetized with 1% lidocaine (Xylocaine),
with no epinephrine, using the digital ring block method.
Tourniquet control of the proximal digit may be accomplished by using a finger of a latex
glove with the distal end cut off or by using a sterile Penrose drain at the base of the
digit firmly secured using a hemostat. The surgery proceeds as follows:
With a No. 15 blade, a crescent-shaped incision is made proximal to the distal
edge of the eponychial fold; the distal incision is made approximately 1 mm
proximal to the distal edge of the eponychium and extends along its curve. A
curvilinear proximal incision is then made, extending from the lateral ends of the
distal incision and forming a crescent with its widest margin approximately 5 mm
from the distal incision; the incision should appear symmetrical
All affected tissue within the boundaries of the crescent and extending down to, but
not including, the germinal matrix is excised
In effect, this procedure exteriorizes the infected and obstructed nail matrix and
allows its drainage
If the nail plate is grossly deformed at the time of surgery, it may be removed
The excised region is packed with plain gauze wick, which is changed every 2-3
days
Epithelialization of the excised defect occurs over the next 2-3 weeks. Nail improvement
occurs over the next 6-9 months but may require as long as 12 months to become
apparent.
Deterrence and Prevention
Patients should also avoid any further trauma to or manipulation of the nail. Hangnails
should be trimmed to a semilunar smooth edge with a clean, sharp nail plate trimmer.
Toenails should be trimmed flush with the toe tip. Patients should not bite the nail plate
or lateral nail folds.
Patients should also avoid prolonged hand exposure to moisture. (Rubber or latex-free
gloves can be worn.) If hand washing must be frequent, patients should use
antibacterial soap, thoroughly dry their hands with a clean towel, and apply an
antibacterial moisturizer.

Medication
Medication Summary
Most paronychia infections can be managed without antibiotics; over-the-counter
analgesics are usually sufficient. If cellulitis is present, however, then antibiotics are
indicated. Although penicillin covers oral flora, it does not cover methicillin-
resistant Staphylococcus aureus (MRSA). Trimethoprim and sulfamethoxazole
(TMP/SMZ), doxycycline, or clindamycin may be considered to cover community-
acquired MRSA and anaerobic organisms. Cephalexin may also be effective.
Combination therapy with an intravenous agent that provides antimicrobial activity
against staphylococci is used for inpatient therapy.
Chronic paronychial infections are usually managed with oral antifungals such as
ketoconazole, itraconazole, or fluconazole. [40] Many of these agents require a prolonged
course with monitoring of laboratory tests to avoid complications.
Antibiotics
Class Summary
Therapy must cover all likely pathogens in the context of this clinical setting.
Clindamycin (Cleocin)
This agent is a lincosamide used in the treatment of serious skin and soft tissue
staphylococcal infections. It is also effective against aerobic and anaerobic streptococci
(except enterococci). Clindamycin inhibits bacterial growth, possibly by blocking the
dissociation of peptidyl transfer ribonucleic acid (t-RNA) from ribosomes, causing RNA-
dependent protein synthesis to arrest.
Clindamycin widely distributes in the body without penetration of the central nervous
system (CNS). It is protein bound and excreted by the liver and kidneys.
Amoxicillin and clavulanic acid (Augmentin, Augmentin XR, Amoclan)
This drug combination is used against bacteria resistant to beta-lactam antibiotics. In
children over age 3 months, base dosing protocol on amoxicillin content. Because the
amoxicillin/clavulanic acid ratio in 250-mg tablets (250/125) is different than in 250-mg
chewable tablets (250/62.5), do not use 250-mg tablets until the child weighs more than
40 kg.
Penicillin VK
Penicillin VK inhibits the biosynthesis of cell wall mucopeptide. It is bactericidal against
sensitive organisms when adequate concentrations are reached. It is most effective
during the stage of active multiplication. Inadequate concentrations may produce only
bacteriostatic effects.
Cephalexin (Keflex)
This is a first-generation cephalosporin that arrests bacterial growth by inhibiting
bacterial cell wall synthesis. It has bactericidal activity against rapidly growing
organisms, with primary activity against skin flora. It is used for skin infections or for
prophylaxis in minor procedures.
Antifungals
Class Summary
The mechanism of action of antifungal agents usually involves the alteration of the
permeability of the cell membrane (polyenes) of the fungal cell or the inhibition of
pathways (enzymes, substrates, transport) necessary for sterol/cell membrane
synthesis.
Miconazole topical (Desenex Spray, Lotrimin AF, Baza Antifungal, Carrington
Antifungal, Micaderm, Micatin)
This agent damages the fungal cell wall membrane by inhibiting the biosynthesis of
ergosterol. By increasing membrane permeability, it causes nutrients to leak out of the
cell, resulting in fungal cell death. Lotion is preferred in intertriginous areas. If cream is
used, it should be applied sparingly to avoid maceration effects.
Ketoconazole (Nizoral, Extina, Xologel)
Ketoconazole has fungistatic activity. An imidazole with broad-spectrum antifungal
action, it inhibits the synthesis of ergosterol, causing cellular components to leak and
resulting in fungal cell death.
Itraconazole (Sporanox, Onmel)
This is a synthetic fungistatic triazole that inhibits cytochrome P-450dependent
synthesis of ergosterol, a vital component of fungal cell membranes.

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