Clinical Assessment

Disclaimer: This is an AI-assisted clinical analysis for educational/supportive purposes only. It is not a substitute for in-person evaluation by a physician. Please seek medical care promptly, especially if there is increasing pain, spreading redness, fever, or pus.

Most Likely Diagnosis: Acute Paronychia with Abscess Formation (possibly a Whitlow/Felon)

Findings from the Image

Differential Diagnosis

• Infection of the proximal/lateral nail fold, most commonly caused by S. aureus, with Streptococcus species also common
• Classic presentation: red, hot, tender, swollen nail fold that progresses to abscess if untreated
• The peeling skin suggests either a resolving bullous component or the blister roof of a superficial abscess that has partially ruptured
• Fitzpatrick's Dermatology: "S. aureus is the major infectious cause of acute paronychia, usually around the fingernails, often originating from a break in the skin, such as a hangnail. Clinically, skin and soft tissue of the proximal and lateral nailfold are red, hot, and tender, and can progress to abscess formation if not treated."

• A purulent abscess involving the bulbous distal pulp/tip of the finger (rather than just the nail fold)
• The involvement here appears dorsal/periungual rather than purely volar, which is more consistent with paronychia
• However, if the swelling extends to the fingertip pulp, this distinction blurs
• Fitzpatrick's: "The finger bulb is red, hot, tender, and edematous, with possible abscess formation" - this can complicate or co-exist with paronychia

• Caused by Group A Streptococcus or S. aureus, more common in children/adolescents
• Presents as a large tense blister on the volar fat pad; can extend to the nail folds
• The extensive peeling skin around the swelling is consistent with a ruptured or resolving bulla
• Andrews' Diseases of the Skin: "characterized by tense superficial blisters occurring on a tender erythematous base over the volar fat pad of the phalanx of a finger or thumb"
• This is the textbook image of blistering dactylitis for comparison:

Key Differentiating Points

Recommended Management

1. Urgent surgical/emergency evaluation - the degree of swelling, violaceous color, and pus suggests this likely needs incision and drainage (I&D)
2. A digital nerve block may be required for the procedure
3. Wound culture should be sent (especially given community-acquired MRSA rates)
4. Antibiotics - systemic antibiotics are typically only indicated if there is significant surrounding cellulitis or the patient is immunocompromised; topical mupirocin may be used for mild cases
5. Ensure tetanus prophylaxis is up to date
6. If blistering dactylitis is confirmed: aspiration of the blister + oral penicillin/amoxicillin-clavulanate is appropriate

• Pfenninger & Fowler's Procedures for Primary Care: "As with all abscesses, it is best to incise and drain (I&D) them once a loculated area of purulence can be identified."