PANCE Blueprint Dermatology (4%)

Patient will present as → a 35-year-old male presents to the clinic with a painful, swollen finger that started three days ago. He reports a history of a puncture wound to the pad of his right index finger while working with wood. Since then, he has noticed increasing redness, swelling, and throbbing pain that worsens when the finger is elevated. He denies fever or systemic symptoms. On physical examination, the distal pulp of the right index finger is erythematous, tense, and warm to the touch. There is tenderness to palpation, with fluctuance, suggesting a localized abscess. The range of motion of the finger is limited due to pain. The patient is diagnosed with a felon, likely caused by Staphylococcus aureus introduced via the puncture wound. Management includes incision and drainage (I&D) to evacuate the abscess and relieve pressure in the finger pulp. A longitudinal incision is made over the affected area to prevent damage to neurovascular structures, and the wound is irrigated thoroughly. A culture is obtained to guide antibiotic therapy. Empiric treatment with an oral antibiotic effective against methicillin-resistant Staphylococcus aureus (MRSA), such as clindamycin or trimethoprim-sulfamethoxazole, is initiated. The patient is instructed to keep the finger elevated, perform warm soaks several times a day, and follow up in 48 hours to monitor for improvement. Signs of worsening infection, such as fever, increasing pain, or spreading erythema, are discussed with the patient, requiring urgent reevaluation.

Felon is an infection of the fingertip pulp space, usually involving the thumb and index finger, typically caused by bacterial invasion, leading to a closed-space abscess

• Penetrating trauma (e.g., splinters, nail biting) is the most common cause, but it can also be a complication of untreated раrοոyсhia
• The most common site is the distal pulp, which may be involved centrally, laterally, or apically
• Most cases are caused by Staphylococcus aureus, including MRSA
• Symptoms include severe throbbing pain, swelling, warmth, and erythema localized to the distal fingertip; may also exhibit tense pressure and fluctuation if an abscess has formed

Apical felon

Diagnosis is clinical, based on characteristic symptoms and physical findings

• Imaging (e.g., X-ray) may be needed to rule out osteomyelitis or foreign bodies
• Ultrasound can confirm the presence of an abscess

Early cases can be managed with warm soaks, elevation, and oral antibiotics (e.g., cephalexin for MSSA or clindamycin/TMP-SMX for MRSA coverage)

• Abscess formation requires incision and drainage (I&D) performed with either a longitudinal or lateral approach, avoiding transverse incisions to prevent neurovascular damage or damage to the flexor tendon sheath
• Culture is obtained to guide antibiotic therapy, and antibiotics should follow I&D if signs of systemic infection or cellulitis are present
• Complications include osteomyelitis, tendon sheath infection, or septicemia if left untreated