Consider referring a patient with paronychia for surgical intervention when there is a fluctuant pus collection or abscess formation that requires incision and drainage but cannot be managed in primary care due to lack of expertise or facilities. In such cases, referral should be made to a surgical unit or Emergency department according to local protocol.
Additionally, urgent referral is warranted if the patient becomes systemically unwell (e.g., develops fever) or shows signs of complications such as cellulitis that extend beyond the local infection.
Referral should also be considered if the paronychia is refractory to initial treatment, especially if there is suspicion of osteomyelitis, in which case imaging such as X-ray may be needed.
For patients with known methicillin-resistant Staphylococcus aureus (MRSA) infection or if MRSA is cultured from the paronychia, specialist advice should be sought.