Hand Infections

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These are emergencies and require early diagnosis and prompt treatment. Staph. spp are responsible for the majority of cases and it is commoner in manual workers, farmers and fishmongers. 

They can be classified as simple or severe infections.

Simple Infections

  • Infections of distal phalangeal pulps Felons (also referred to as whitlow or pulp space infection)
  • Paronychia (acute and chronic)
  • Sub-epithelial blisters and abscesses
  • Herpes
  • Septic granulomas
  • Carbuncular infections (from sebum of hair follicles and sweat glands)

Severe Infections

  • Suppurative tenosynovitis
  • Fascial space abscesses
  • Acute osteomyelitis
  • Acute septic arthritis
  • Acute Lymphangitis and allied infections
  • Combinations 
  • Complications of acute infections

Cause

  • Staph. aureus and epidermidis
  • Strept. pyogenes
  • Fungi
  • Viruses 

Symptoms

  • Pain
  • Swelling 
  • Blistering 
  • Fever 
  • Skin discoloration 
  • Loss of function

Note: In chronic types there may be no pain or fever. 

Signs

  • Fever 
  • Swelling 
  • Tenderness 
  • Discharge 
  • Stiffness 

Investigations

  • FBC, ESR
  • CRP
  • Blood culture
  • Random blood sugar
  • Gram stain and culture of discharge
  • X-ray
  • Nail clippings for chronic paronychia

TreatmentTreatment Objectives

  • Eradicate infection early and aggressively
  • Prevent complications such as stiffness of the joints and septicaemia

Non-pharmacological treatment

  • Elevation of the affected hand
  • Bandaging
  • Protective wear
  • Physiotherapy 
  • Surgical drainage of abscesses 
  • Fasciotomy in compartment syndrome 

Pharmacological treatment See sections below

Referral Criteria

Refer to appropriate specialists if patient does not improve.

Treatment of suspected simple Staph. infections

1st Line Treatment

Evidence Rating: [B]

  • Flucloxacillin, oral,

Adults

250-500 mg 6 hourly for 7-14 days

Children

5-12 years; 250 mg 6 hourly for 7-14 days

1-5 years; 125 mg 6 hourly for 7-14 days 

<1 year; 62.5 mg 6 hourly for 7-14 days

2nd Line Treatment

Evidence Rating: [B]

  • Clindamycin, oral,

Adults

150-300 mg 6-8 hourly for 7-14 days

Children

12-18 years; 150-300 mg 6 hourly for 7-14 days 

1 month-11 years; 3-6 mg/kg 6 hourly for 7-14 days

Treatment of suspected severe Staph. infections

For treatment of suspected severe Staph. infections

1st Line Treatment

Evidence Rating: [B]

  • Cloxacillin, IV, 

Adults

500 mg 6 hourly for 7-14 days

Children 

5-12 years; 250 mg 6 hourly for 7-14 days

1-5 years; 125 mg 6 hourly for 7-14 days

< 1 year; 62.5 mg 6 hourly for 7-14 days

2nd Line Treatment 

  • Clindamycin, IV/IM,

Adults 

300-600 mg 8 hourly for 14 days

Children

12 years-18 years; 150-675 mg 6 hourly for 14 days

1 month-12 years; 3.75-6.25 mg/kg 6 hourly for 14 days

For treatment of chronic paronychia

1st Line Treatment

Evidence Rating: [B]

  • Itraconazole, oral,

Adults

200 mg daily for 7 days 

Children

> 12 years; 200 mg daily for 7 days

1 month-12 years; 3-5 mg/kg daily for 7 days

Caution: Use of itraconazole is associated with potentially life-threatening liver-toxicity. Monitor liver function while on long term therapy.

And 

  • Miconazole tincture, topical,

Adults and Children > 2 years 

Apply 12 hourly to affected area

2nd Line Treatment 

Evidence Rating: [B]

  • Fluconazole, oral,

Adult

150-300 mg weekly

Children

12-18 years; 50-100 mg weekly

14 days-12 years; 3-6 mg/kg weekly 

Or

  • Clotrimazole, topical,

Adults and Children

Apply 8-12 hourly to affected area

Or

  • Nystatin cream, topical,

Adults and Children

Apply 8-12 hourly to affected area

Or

  • Econazole cream, topical,

Adults and Children 

Apply 8-12 hourly to affected area

Or 

  • Ciclopirox cream, topical,

Adults 

Apply 8-12 hourly to affected area 

Children

> 10 years; apply 8-12 hourly to affected area

< 10 years; not recommended

3nd Line Treatment 

Evidence Rating: [C]

  • Griseofulvin, oral, 

Adults

500 mg daily (double in severe infection) for 4 weeks

Children

12-18 years; 500 mg once daily or in two divided doses (may be doubled in severe infections) for 4 weeks

1 month-12 years; 10  mg/kg  (max.  500  mg)  once  daily  or  in  two divided doses for 4 weeks

And 

  • Miconazole tincture, topical,

Adults and Children

Apply 12 hourly to affected area

For treatment of septic granuloma

1st Line Treatment 

  • Copper sulphate stone (blue stone), topical,

Adults and Children

Apply to the affected site 12 hourly

Or

Evidence Rating: [B]

  • Hydrocortisone cream, 0.5-2.5%, topical,

Adults (0.5-2.5%)

Apply 8-12 hourly to affected area(s)

Children (0.5-1%)

Apply 8-12 hourly to affected area(s)

Or

  • Clobetasol propionate cream (0.05%), topical,

Adults 

Apply 8-12 hourly to affected area(s)

Children

> 12 years; apply 8-12 hourly to affected area(s)

< 12 years; not recommended 

Or 

  • Betamethasone dipropionate cream (0.05%), topical,

Adults and Children < 12 years

Apply 12 hourly to affected area(s)