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  • William W. Forgey, MD

Soft Tissue Care And Trauma Management Part 4 - Finger / Toe Problems, Wound Infection and Skin Rash

Updated: Sep 24

Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.



Ingrown Nail

This painful infection along the edge of a nail can, at times, be relieved with warm soaks. There are several maneuvers that can hasten healing, however. One technique is a taping procedure, shown in figure 6-12. A piece of strong tape (such as waterproof tape) is taped to the inflamed skin edge next to—but not touching—the nail. The tape is fastened tightly to this skin edge with gentle but firm pressure. By running the tape under the toe or finger, the skin edge can be tugged away from the painful nail and thus relieve the pressure.

Another method is to shave the top of the nail by scraping it with a sharp blade until it is thin enough that it buckles upward. This “breaks the arch” of the nail and allows the ingrown edge to be forced out of the inflamed groove along the side.


The above techniques should be implemented at the first sign of irritation rather than once infection has developed, though even then they are effective. Provide antibiotics such as doxycycline, 100 mg twice daily, or Levaquin, 500 mg once daily.


Paronychia (Nail Base Infection)

Paronychia, an infection of the nail base, is a very painful condition that should initially be treated with warm soaks, 15 minutes every 2 hours, and the use of oral antibiotics such as doxycycline, 100 mg twice daily, or Levaquin, 500 mg daily. Oral pain medication will also be necessary. If the lesion does not respond within 2 days, or if it seems to be getting dramatically worse, an aggressive incision with a sharp blade will be necessary, as shown in figure 6-13.This wound will bleed freely; allow it to do so. Change bandages as necessary, and continue the soaks and medications as described under Abscess (page 147).

Felon

A deep infection of a fingertip is called a felon. It results in a tense, tender finger pad. Soaking a felon prior to surgery, unlike other infections, does not help and only increases the pain. Treatment is effected by a very aggressive incision, called a fish-mouth incision, made along the tip of the finger from one side to the other and extending deep to the bone; see figure 6-14.


An alternate incision is a through-and-through stab wound going under the finger bone, from one side to the other. A gauze or sterile plastic strip is then inserted through the wound to promote drainage of the pus from the felon.


The pain is severe and not helped by local injection of lidocaine. But relief is quick as pressure from the pus buildup is alleviated. Allow this wound to bleed freely. Soak in warm water for 15 minutes every 2 hours until drainage ceases (about 3 days). Give pain medication about 1 hour prior to your surgical procedure, using the strongest that you have in your kit. Simultaneously start the victim on an antibiotic such as Levaquin, 500 mg once daily; doxycycline, 100 mg twice daily; or Rocephin, 500 mg IM twice daily.


Blood under the Nail

Blood under a fingernail or toenail, called subungual hematoma, is generally caused by a blow to the digit involved. The accumulation of blood under a nail can be very painful. Relieve this pressure by twirling the sharp point of a blade through the nail (using the lightest pressure possible) until a hole is produced and draining effected. This is a painless procedure and the tip of the blade should not enter the nail bed, only the pocket of blood under the nail. Soak in cool water to promote continual drainage of this blood. The finger may still hurt from the contusion, however, so additional pain treatment with Percogesic, 1 or 2 tablets every 4 hours, or Norco 10/325, 1 tablet every 4 to 6 hours, may also be useful. Antibiotic use is not necessary.


WOUND INFECTION AND INFLAMMATION

Lacerations that have been cleaned and either sutured, taped, or stapled together will generally become slightly inflamed. Inflammation is part of the healing process and does not indicate infection, yet the appearance is similar; it’s a matter of degree. Inflammation has slight swelling and red color. The hallmarks of infection are swelling, warmth to touch, reddish color, and pain. Pus oozing out of a wound is another clue. If the cut has a red swelling that extends beyond 1/4 inch from the wound edge, infection has probably started.


The method of treatment of wound infection is quite simple. Remove some of the tapes, sutures, or staples and allow the wound to open and drain. Apply warm, moist compresses for 15 to 20 minutes every 2 hours. This will promote drainage of the wound and increase the local circulation, thus bringing large numbers of friendly white blood cells and fibroblasts into the area. The fibroblast tries to wall off the infection and prevent the further spread of germs. Once an infection has obviously started, the use of an antibiotic will be helpful but is not always essential. From the Rx Oral/Topical Medication Module, use evaquin, 500 mg once daily. If the Rx Injectable Medication Module is available, use Rocephin, 500 mg twice daily IM or 1,000 mg once daily IM.


Abscess

An abscess (boil or furuncle) is a pocket of pus (white blood cells), germs, and red blood cells that have been contained by an envelope of scar tissue produced by fibroblasts. This protects the body from the further spread of germs. It is part of the body’s strong natural defense against invasion by bacteria. Conversely, many antibiotics cannot penetrate into the abscess cavity very well. The cure for an abscess is surgical. It must be opened and drained.


There are two basic ways in which this can happen. First, moist warm soaks will not only aid in abscess formation but will also aid in bringing the infection to the surface and cause the infection to “ripen,” even open and drain on its own. An abscess can be very painful and this opening period very prolonged. Once the abscess is on the surface, it is generally better to open it using a technique called incision and drainage, or I&D. The ideal instrument for I&D is a thin, sharp blade. Use the blade to penetrate the surface skin and open the cavity with minimal pressure on the wound.


Abscesses are very painful, primarily because of the pressure within them. A person coming into a doctor’s office with a painful abscess would expect to have it anesthetized before opening. Injections into these areas only add to the pain. The best anesthesia is to cool the wound area. In the field an ice cube or application of an instant cold pack will help provide some anesthesia. A person with a painful abscess will usually let you try the knife, as they can become desperate for pain relief. The relief that they get when the pressure is removed is immediate, even without cooling.


Coat the skin surface around the abscess with triple antibiotic ointment from the Topical Bandaging Module to protect the skin from the bacteria that are draining from the wound. Spread of infection from these bacteria is unlikely, however, unless the skin is abraded or otherwise broken.


Cellulitis

Cellulitis is a very dangerous and rapidly progressive skin infection that results in red, painful swelling of the skin without pus or blister formation. The lesion spreads by the hour, with streaks of red progressing toward the heart ahead of the swelling. This represents the travel of infection along the lymphatic system and is frequently called blood poisoning in the vernacular. While lymphatic spread is not strictly blood poisoning, cellulitis does frequently lead to generalized blood poisoning (septicemia) and can cause the development of chills, fever, and other symptoms of generalized profound infection, such as lethargy and even shock. Very dangerous and virulent germs are responsible. Strong antibiotics are necessary, and the application of local heat is very helpful.


Old-time remedies included the use of various “drawing salves,” but nothing works better than local hot compresses. Local heat increases the circulation of blood into the infected area, bringing white cells that will kill the bacteria directly and produce antibodies to aid in killing the germs. The infection fighters, and the walling-off process of the fibroblasts, will hopefully contain and destroy the infection. When this walling off process succeeds, an abscess is formed (see preceding section). If the Rx Injectable Medication Module is available, give Rocephin, 500 mg IM twice daily. Or, if only the Rx Oral/Topical Medication Module is available, give doxycycline, 100 mg twice daily, or Levaquin, 500 mg once daily.


SKIN RASH

A rash is a frequent outdoor problem. At times a rash is associated with certain diseases and can help in the diagnosis. If the patient is feverish or obviously ill, review the sections on Lyme disease, Rocky Mountain spotted fever, typhoid fever, syphilis, meningococcal meningitis, strep throat, measles, and mononucleosis in chapter 9.

Many infections that cause rash are viral and will not respond to antibiotics. But, with no professional medical help available, rash associated with symptoms of illness, particularly fever and aching, should be empirically treated with an antibiotic such as doxycycline, 100 mg twice daily, for at least 2 days beyond the defervescence (loss of fever). Some of the above infections require longer antibiotic treatment, so it should be continued as indicated if there is a probability that you are dealing with one of them.


Localized rashes without fever are usually due to superficial skin infections, fungal infections, or allergic reactions. Itch can be treated with antihistamine or any pain medication. The Non-Rx Oral Medication Module has diphenhydramine, 25 mg, as an antihistamine. One capsule (2 in severe cases) every 6 hours will help with itch from nearly any cause.


As itch travels over the same nerves that carry the sensation of pain, any pain medication can also help with itch. Warm soaks generally make itch and rash worse and should be avoided, unless there is evidence of deep infection (see Abscess and Cellulitis above). It is hard to do better than diphenhydramine with regard to oral antihistamine effect, but it should be noted that Atarax (in the Rx Oral/ Topical Medication Module), and the same medication in injectable form, Vistaril (in the Rx Medication Injectable Module), also have antihistamine action and can be used for itch. Also soothing to either a non-weeping lesion or a blistered and weeping lesion is the application of a piece of Spenco 2nd Skin from the Topical Bandaging Module. Cool compresses will also soothe a rash.


For a moist, weeping lesion (this includes poison ivy, poison oak, and poison sumac), wet soaks of dilute Epsom salts, boric acid, or even table salt will help dry it. If it is a dry, scaly rash, an ointment works best, much better than a gel, lotion, or cream. Blistered rashes are treated best with creams, lotions, or gels. Specific types of rashes require specific types of topical medications, however.


Fungal Infection

A fungal infection is commonly encountered in the groin, in the armpit, in skin folds, on the scrotum, under a woman’s breasts, and around the rectum. Rashes can range from bright red to almost colorless but are generally at least dull red, and frequently have small satellite spots near the major portion of confluent rash. Fungal infections are very slow in spreading, with the lesions becoming larger over a period of weeks to months. Body ringworm is a circular rash with a less intense center area (caution: see Lyme Disease, page 228).

Fungal rashes should be treated with a specific antifungal, such as clotrimazole 2% cream from the Topical Bandaging Module. Apply a thin coat twice daily. Good results should be obtained within 2 weeks for jock itch, but athlete’s foot and body ringworm may take 4 weeks and need to have continued treatment until all evidence of rash is gone, then treatment continued once daily for an additional 3 weeks. If no improvement has been made, the diagnosis may have been wrong, or the fungus is refractory to your medication. From the Rx Oral Medication Module, Diflucan, 150 mg, daily will destroy most body surface fungal infections, but it is included in only a small quantity for primary use in the treatment of vaginitis.


Allergic Dermatitis

The hallmarks of allergic dermatitis are vesicles, or small blisters, on red, swollen, and very itchy skin. A line of these blisters clinches the diagnosis of allergic, or contact, dermatitis. The most common culprits are poison ivy, poison sumac, and poison oak. Contact with caterpillars, millipedes, and many plants—even such innocent species as various evergreens—can also induce allergic or toxic skin reactions.


A toxic reaction to a noxious substance, such as from certain insects and plants, is treated like an allergic dermatitis. First aid treatment is a thorough cleansing with soap and water. Further treatment is with diphenhydramine, 25 mg every 6 hours, from the Non-Rx Oral Medication Module, and twice daily applications of hydrocortisone cream 1% from the Topical Bandaging Module. Weeping lesions can be treated with wet soaks as mentioned above. An occlusive plastic dressing will allow the rather weak 1% hydrocortisone to work much better.


The Rx Oral/Topical Medication Module has two very effective medications to treat this problem. Continue use of the diphenhydramine, but add Decadron, 4 mg tablet, 1 daily for 5 to 7 days, and apply Topicort 0.25% ointment in place of the hydrocortisone cream. A thin coat twice daily without an occlusive plastic dressing should work rapidly.


Stinging nettle causes a severe irritation that can be instantly eliminated by the application of “GI jungle juice,” a mixture of 75% DEET insect repellent and 25% isopropyl (rubbing) alcohol. I discovered this neat trick the hard way (accidentally) while camping in fields of the stuff along the Cape Fear River in North Carolina. Since mentioning this in the first edition of my book Wilderness Medicine in 1979, many others in contact with this plant have confirmed the treatment’s instantaneous effectiveness.


Bacterial Skin Rash

A common bacterial superficial skin infection causing a rash is impetigo. The normal appearance of this condition is reddish areas around pus-filled blisters, which are frequently crusty and scabbed. The lesions spread rapidly over a period of days. The skin is generally not swollen underneath the lesions. It often starts around the nose and on the buttocks, spreads rapidly from scratching, and can soon appear anywhere on the body. Early lesions appear as small pimples, which form crusts within 12 to 24 hours. Lesions should be cleaned with surgical soap (or hydrogen peroxide) and then covered with an application of triple antibiotic ointment. Avoid placing bandages on these lesions, as the germs can spread under the tape.


Bacterial skin infections generally must be treated with prescription antibiotics. From the Rx Oral/Topical Medication Module, give Levaquin 500 mg once daily. The Rx Injectable Medication Module contains Rocephin, which would be ideal for this condition; give 500 mg IM once daily.


Treatment of abscess and cellulitis, forms of deep skin infections, are discussed on pages 147 and 148.


See pages 61–62 for treatment of cold sores and lip or mouth lesions.


Seabather’s Eruption

Seabather’s eruption is the term used for the sudden onset of a very itchy rash associated with swimming. In south Florida and the Caribbean, it is caused by larvae of the thimble jellyfish (Linuche unguiculata) or by the larvae of the sea anemone (Edwardsiella lineata). The latter was shown to be responsible for thousands of cases on Long Island, New York. Global warming will probably cause this condition to become a problem much farther north than that.


Welts (urticaria) or a fine red or pimply rash appears within 24 hours of exposure to ocean water, normally in areas covered by bathing suits.The tiny larvae are trapped next to the skin within the bathing suit and discharge nematocysts that cause the disease. Additional symptoms frequently associated with this rash include fever, chills, weakness, and headache, as the larvae penetrate the skin and cause illness. In south Florida the occurrence is from March to August, with a peak of outbreaks in May. In Long Island waters the outbreaks occur from mid-August until the end of the swimming season in early September. These outbreaks are episodic, with very few cases some years and thousands of cases during peak years.


Treatment consists of topical corticosteroid (1% hydrocortisone cream from the Topical Bandaging Module applied 4 times daily, or 0.25% Topicort ointment from the Rx Oral/Topical Medication Module applied twice daily) and antihistamine (diphenhydramine, 25 mg) from the Non-Rx Oral Medication Module taken 4 times a day. Swimmers should remove bathing suits and shower as soon as possible after leaving the water. And swimming at a nude beach doesn’t protect you just because you are not wearing a bathing suit.



View related Soft Tissue Care And Trauma Management posts




Part 1 - The Bleeding Wound



Part 2 - Wound Closure Techniques



Part 3 - Special Considerations and Other Types of Wounds







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