MBBS OSCE · Dermatology / Hand infection / Primary Care
OSCE — painful nail fold: acute paronychia vs herpetic whitlow vs chronic wet-work disease
An 8-minute OSCE distinguishing acute bacterial paronychia, herpetic whitlow (never incise), felon, green nail syndrome, and chronic irritant/Candida paronychia with tacrolimus and wet-work avoidance.
8 min stationSource-verified ·
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Study tools
Exam tags
NEET-PGINICETUSMLEPLABMRCP
Brief (to candidate)
A chef presents with a tender swollen proximal nail fold on one finger; a dental student has fingertip vesicles with burning pain; a third has multi-finger boggy nail folds with lost cuticles after years of wet work. You have 8 minutes to differentiate entities and treat safely — including when NOT to incise.[1]
Candidate instructions
- Diagnose acute bacterial paronychia and treat (soaks, I&D if abscess, antibiotic).[1]
- Recognise herpetic whitlow and avoid incision.[1]
- Distinguish felon (pulp closed-space abscess).[1]
- Manage chronic paronychia as irritant dermatitis ± Candida.[1]
- Mention green nail (Pseudomonas) and drug-induced paronychia.[1]
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Acute bacterial | Usually S. aureus, single digit, erythema/pain ± fluctuant abscess; warm soaks; I&D along nail fold if pus; oral flucloxacillin 500 mg QDS 5–7 days if cellulitis (or local equivalent)[1][6] |
| Herpetic whitlow | Grouped vesicles, burning/tingling, often healthcare workers; DO NOT INCISE; PCR if needed; oral aciclovir/valaciclovir; infection control counselling[5][1] |
| Felon | Pulp space abscess — severe pulp pain/tension; needs prompt surgical drainage, not simple nail-fold nick alone |
| Chronic paronychia | Multi-digit, cuticle loss, wet-work occupational; primarily irritant contact dermatitis with secondary colonisation; dry work, cotton-lined gloves, emollient/barrier; topical tacrolimus 0.1% BD weeks; fluconazole/doxycycline if indicated; eponychial marsupialisation if refractory[7][8][1] |
| Green nail | Pseudomonas/pyocyanin green discoloration — acetic acid soaks ± topical antipseudomonal measures; address onycholysis |
| Drug-induced | Retinoids, EGFR/MEK inhibitors, etc. cause periungual inflammation/pyogenic granuloma — oncology liaison, topical care, rarely dose adjust |
| Communication | Occupational modification critical for chronic disease; nail regrowth takes months |
Model key actions
- Incise bacterial abscess paronychia; never incise herpetic whitlow.[1][5]
- Treat chronic multi-finger cuticle-loss disease as wet-work irritant dermatitis first.[7]
- Use tacrolimus steroid-sparing pathway for chronic paronychia evidence base.[8]
Common errors
- Incising herpetic whitlow.[1]
- Antibiotics alone for chronic wet-work paronychia without barrier measures.[1]
- Missing felon requiring deeper drainage.[1]
- Ignoring green nail as Pseudomonas colonisation of onycholytic nail.[1]
References6ShowHide
- [1]Leggit JC Acute and Chronic Paronychia. Am Fam Physician, 2017.PMID 28671378
- [2]Lee DK, Lipner SR. Optimal diagnosis and management of common nail disorders. Ann Med, 2022.PMID 35238267
- [5]Iorizzo M, Pasch MC Bacterial and viral infections of the nail unit: Tips for diagnosis and management. Hand Surg Rehabil, 2024.PMID 36427761
- [6]Rerucha CM, et al. Acute Hand Infections. Am Fam Physician, 2019.PMID 30763047
- [7]Relhan V, Goel K, Bansal S, et al. Management of chronic paronychia. Indian J Dermatol, 2014.PMID 24470654
- [8]Rigopoulos D, et al. Efficacy and safety of tacrolimus ointment 0.1% vs. betamethasone 17-valerate 0.1% in the treatment of chronic paronychia. Br J Dermatol, 2009.PMID 19120329