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Hello,
I need some assistance in dealing with a case I am dealing with. A patient came into my practice with infected halluxes. They are inflamed and have created a slight reddish tinge on the two toes. The issue is that the patient (a 16 year old) has been on roaccutane or accutane. The medication causes a whole range of side effects but the two side effects that have affected the patient are paronychia and excessive granulation. The patient has previously been on Augmentin, Cephalexin and is currently on Dicloxacillin. He stated that he has had the issue for around 6 months and that the antibiotics have only slightly repelled the infection. His right hallux has infections on both sides of the toe and his left hallux is only affected on one side. And finally on a recent swab test they found pseudomonas. I can attach images if required.
What do you guys and girls recommend?
Thank you for your assistance!

Kind Regards, eddy

 

Hello eddie9898,

:welcome:

A picture would be very useful if you could post one.

Is this patient under a Consultant Dermatologist? The reason I ask this is because in UK roaccutane is usually only prescribed by a consultant.

regards

Catfoot

 

Same in Aus - only available for prescription by a dermatologist who must request authorisation to prescribe

Nick

 

The antibiotics prescribed are not anti-pseudomonals.

Ciprofloxacin is the ONLY ORAL anti-pseudomonal antibiotic.

The other first line anti-pseudomonals (Timentin, Tazocin, Gentamyin, Tobramycin, Ceftazidime, Cefepime) are administered IV.

 

Hello Eddy

According to the BNF Isotretinoin is prescribed for at least 16 weeks and repeat doses are not normally required. Paronychia and granuloma have been noted as side effects, but this does not necessarily mean that this is the case here. Sadly, lots of spotty lads suffer from paronychia!

For what it's worth, my advice would be to have him treated with ciprofloxacin, as suggested by John, and if the granulation does not resolve then to carry out procedures such as Winograds or Frost excisions. However, it would be responsible and professionally correct to contact the consultant dermatologist and work in concert with him/her.

Please post the results.

All the best

Bill

 

Perhaps a surgical debridement of the nail boarders with lots of irrigation.

 

Totally agree, especially liaising with his dermatologist.

However, assuming he's taking the meds for his acne, surely it would be best to wait until he's finished his course(s) of isotretanoin before you do any nail procedures?
Isotretanoin is very strong and side effects usually clear up once the course of meds has stopped.

 

Hi Eddy

Your swab results indicate a the presence of a Pseudomonas infection. The use of acetic acid, an up to 3% preparation, is usually effective for this topically.