Blistering distal dactylitis

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Blistering distal dactylitis is a variant of streptococcal skin infection. It presents as a superficial, tender, blistering beta-haemolytic streptococcal infection over the anterior fat pad of the distal phalanx of the finger (Figure 5.40). The lesion may or may not have a paronychial extension. This blister, containing thin, white pus, has a predilection for the tip of the digit and extends to the subungual area of the free edge of the nail plate. The area may provide a nidus for the beta-haemolytic streptococcus and act as a focus of chronic infection similar to the nasopharynx. The age range of affected patients is 2-16 years. For local care incision, drainage and antiseptic soaking are indicated, giving a more rapid response than systemic antibiotic therapy alone: effective regimens include benzylpenicillin (penicillin G) in a single intramuscular dose, a 10-day course of oral phenoxymethylpenicillin or eryhromycin ethyl succinate. This type of treatment decreases the reservoir of streptococci by preventing spread to family contacts. This infection has been described as a complication of ingrowing toe nail. The differential diagnosis includes blisters resulting from friction, thermal and chemical burns, infectious states such as herpetic whitlow, staphylococcal bullous impetigo and the Weber-Cockayne variant of epidermolysis bullosa simplex.


Figure 5.40

Blistering distal dactylitis.

Chronic paronychia and thumb sucking

Candidal paronychia, usually in association with oral candidiasis, may arise as a result of chronic maceration due to thumb sucking (Figure 5.41). Chronic paronychia is not uncommon in children. It differs from the condition seen in adults in the source of the maceration, associated diseases, the clinical appearances of the lesion, and the patient's responses to the symptoms. In children the lesions are generally prominent, with total involvement of the proximal nail fold. The skin is usually erythematous and glistening owing to the wet environment produced by continuous thumb sucking. The quality of the nail is always altered, resulting in a poor texture. The habit of sucking fingers or thumbs is the most important predisposing factor. Candida albicans is present in all cases. When an acute flare-up occurs the patient experiences pruritus and discomfort in the proximal nail fold. Children respond to this by sucking—the symptoms of chronic paronychia perpetuating the habit that initiated the maceration. The lesions tend to be more severe in childhood than in adult paronychia, probably because thumb sucking is more continuous than exposure to wet work, and saliva is more irritating than water. The minor repeated trauma resulting from suction is capable of causing complete loss of the nail plate. Detection of the carrier state in the mouth and gastrointestinal tract by cultures of saliva and stools may be important in the occasional patient with refractory paronychia. Persistent and repeated candidal paronychia in infancy suggests a more serious underlying disorder and such infants should be investigated for endocrine disease and immune deficiency syndromes.

Figure 5.41

Chronic paronychia caused by thumb sucking in an atopic individual.

Figure 5.41

Chronic paronychia caused by thumb sucking in an atopic individual.

Thumb or finger sucking is sometimes associated with herpes simplex. This may result in local extension of the eruption producing viral stomatitis combined with involvement of the digit. In childhood, local trauma, caused by onychophagia, may result in the development of opportunistic infection by the normal oropharyngeal flora, amongst which are found HB 1 bacteria. Acute paronychia may also be caused by HB 1 organisms (Eikenella corrodens), but this is uncommon in the absence of immune deficiency.

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