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Blistering distal dactylitis


Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports

Courtesy of Joseph Bikowski, MD

Blistering distal dactylitis (BDD) is a superficial, tender, blistering infection seen in childhood and the early teens. It is usually caused by group A β-hemolytic streptococci, although group B organisms, staphylococci, and, more recently, methicillin-resistant Staphylococcus aureus (MRSA) have also been implicated. The distal volar fat pads of the fingers are the most common site of infection, but more extensive involvement of the nailfolds and toes can occasionally occur.

Management Strategy

BDD can cause considerable alarm to parents, as large, tense blisters rapidly develop. Despite the absence of constitutional symptoms, patients usually seek help soon after the onset of the infection. The condition does not resolve spontaneously, but prompt treatment results in rapid improvement. Blisters should be incised to release fluid , which can vary from clear and watery to frank pus. Subsequent application of topical antibiotics can be helpful, but systemic treatment is usually also required. Penicillin V is the treatment of choice for streptococcal infection, but erythromycin is an effective alternative for patients allergic to penicillin. It is important to exclude MRSA or immunosuppression for resistant cases.

The differential diagnosis of the condition includes traumatic blisters, herpetic whitlow, staphylococcal bullous impetigo, and the Weber–Cockayne variant of epidermolysis bullosa.

Specific Investigations

  • Gram stain of blister fluid

  • Culture of blister fluid

  • Swab of nasopharynx for bacteriology

A clinically recognizable streptococcal infection

Hays GC, Mullard JE. Paediatrics 1975; 56: 129–31.

First large series report describing 13 patients with BDD. Streptococci were found on culture of blister fluid in all cases, and Gram-positive cocci were usually found on Gram staining. This report suggests a link with infection of the nasopharynx, but this has not been confirmed in other case reports.

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