Paronychia in a Child

The patient is an eight year-old girl with a three week history of paronychial inflammation. Mild pain at onset and now. No history of trauma or finger sucking. She was first seen by her pediatrician around ten days after onset and told it was improving and to give it time. No improvement after ten days; given a ten day course of cephalexin and urged to do warm soaks. No improvement noted. Seen in Dermatology Clinic October 26, 2007.



































Examination: Marked inflammation of proximal and lateral nail folds. No fluctuance. Perhaps, mild pain. No discharge. KOH from chalky material at proximal nail fold negative. The entire nail is dystrophic, perhaps suggesting longer involvement,

Questions:
Is this an acute bacterial or a chronic candidal paronychia?
Should the proximal nail fold be explored?
Other than bacterial and fungal cultures, any further studies?
What would you do at this point?