Visual Diagnosis

Case: A 2-year-old boy presents with acute swelling and tenderness of the great toe after wearing new shoes for the past week.

Diagnosis:

This patient has a blistering distal dactylitis.

This condition presents as a tense, painful blister on an erythematous base located over the volar fat pad of a distal phalanx. Involvement of the palmar surface and proximal phalanxes of the hands or feet may also occur. Single or multiple digits may be affected. Group A beta-hemolytic streptococcal infection has been identified as the most common organism causing this local infection. Staphylococcus aureus and Group B streptococcal infections have occasionally been implicated. Both children (especially between the ages of 2 and 16 years) and adults (particularly the immunocompromised) can be affected, though it has not reported in the elderly patient.

Clinical Practice Pearls:

• Systemic complaints are rare.


• Coexisting infection with herpetic whitlow can occur.


• Treatment includes incision and drainage or needle aspiration of fluid, followed by warm compresses and oral beta–lactamase-resistant antibiotics. Fluid can be sent for gram-stain and/or culture.

Further Reading:

• Scheindfeld NS. Is blistering dactylitis a variant of bullous impetigo? Clin Exp Dermatol. 2007;32(3):314-316.
• Ney AC. English JC 3rd, Greer KE. Coexistent infections on a child’s distal phalanx: blistering dactylitis and herpetic whitlow. Cutis. 2002;69(1):46-48.