A Diagnostic and Treatment Difficulty

Herpetic whitlow is an acute viral infection of the hand caused by either herpes simplex virus (HSV) 1 or 2. Its characteristic findings are significant pain and erythema with overlying nonpurulent vesicles. The differential diagnosis includes flexor tenosynovitis. We present a case of recurrent infection of the middle finger in an immunocompetent 19-year-old girl. Multiple painful pustules with tracking cellulitis were partially treated by oral antibiotics. A recurrence with positive Kanavel’s signs suggested flexor tenosynovitis at seven months. Her symptoms improved transiently following emergent surgical open flexor sheath exploration and washout however, she required two further washouts; at eleven and thirteen months to improve symptoms. Viral cultures were obtained from the third washout as HSV infection was disclosed from further history taking. These were positive for HSV2. Treatment with acyclovir at thirteen months after presentation led to a complete resolution of her symptoms with no further recurrences to date. This rare case highlights the similarity in presentation between flexor sheath infection and herpetic whitlow which can lead to diagnostic confusion and mismanagement. We emphasise the importance of careful past medical history taking as well as considering herpetic whitlow as a differential diagnosis despite the presence of strongly positive Kanavel’s signs.

1. Introduction

Herpetic whitlow is an acute viral infection of the hand caused by herpes simplex virus (HSV 1/HSV 2). Its characteristic findings are significant pain and localised erythema followed by development of small nonpurulent vesicles. Differential diagnoses include flexor tenosynovitis, bacterial felon, and paronychia [1]. The similarity in presentation between flexor sheath infection and herpetic whitlow can lead to diagnostic confusion and mismanagement. This can be aggravated further when Kanavel’s cardinal signs are strongly positive. We present our case of recurrent finger infection in a 19-year-old female and we emphasise the importance of careful past medical history taking which can help in reaching an accurate diagnosis as well as considering herpetic whitlow as a differential diagnosis despite the presence of Kanavel’s signs.

2. Case Report

A 19-year-old girl presented to her General Practitioner with a painful erythematous middle finger with tracking erythema up the arm. She was started on oral antibiotics (Flucloxacillin) for presumed cellulitis. She was and remained systemically well; however, she required hospital admission three days later when infection failed to respond to antibiotics. The finger was noted to be more swollen and exquisitely painful with reduced range of movement. Clinical examination revealed small, firm, circular, and painful pustules along with erythema spreading to the level of axilla accompanied by regional lymphadenopathy. Kanavel’s cardinal signs were all positive including intense pain on attempting to extend her partially flexed finger, flexion posture, uniform swelling, and percussion tenderness. The decision was made to proceed with surgical open flexor sheath exploration and washout. Clear fluid was noted and specimens were sent for standard culture and sensitivity. These came back negative; however, symptoms did resolve following washout.

Seven months later, the patient presented with similar symptoms, however, this time, with more localised symptoms to the finger only. A repeat flexor sheath washout was undertaken which resulted in symptomatic improvement. A similar third presentation four months following the second presentation was treated in the same fashion. A biopsy was obtained on this occasion with cultures and sensitivities for atypical organisms; these were negative.

Two months after the third washout, she was rereferred to the hand service by her General Practitioner with a painful swollen middle finger partially covered with multiple small pustules as seen in Figures 1, 2, 3 and 4. However, Kanavel’s signs were not present this time. A more detailed history revealed a pervious herpes simplex virus (HSV) infection as a child. The pustules were surgically deroofed and thick fluid was drained in theatre. Samples of tissue and fluid were sent for microbiological analysis including a swab in a viral transport medium. HSV type 2 was confirmed following a positive culture and polymerase chain reaction (PCR). The diagnosis of herpetic whitlow was established. She received 200 mg of Acyclovir five times a day for seven days and, at thirteen months after presentation, this led to complete resolution of her symptoms with no further recurrences up to the time of writing.

3. Discussion

The first published report of herpetic whitlow of the finger in adults was in 1909 by Adamson [2]. The classical vesicles tend to arise after a few days of skin irritation or minor trauma and may include a prodromal period of flu-like symptoms. Herpetic whitlow is a clinical diagnosis and its treatment differs greatly from other common hand infections; thus, special attention must be paid to examination findings and history alike.

Vesicles are usually clear or pale yellow, have a base which is erythematous, and can coalesce into a single vesicle [3]. Regional lymphadenopathy may accompany these findings; however, systemic symptoms are rare [4].

The flexor sheath infection should be considered in the differential diagnosis of a painful swollen digit and Kanavel’s signs [5] are in most cases a useful tool. The absence of these signs and the presence of vesicles aid the diagnosis and guide further management of herpetic whitlow. However, in even rarer cases, as in our case, the presence of these signs does not preclude the diagnosis of herpetic whitlow which should be considered in recurrent refractory cases. We therefore feel that herpetic whitlow can present in atypical way and can very rarely largely mimic flexor sheath infection presenting with positive Kanavel’s signs making the correct diagnosis more challenging. We emphasise the importance of detailed past medical history, careful clinical examination, and careful assessment of Kanavel’s signs as well as early consideration of viral cultures in recurrent cases.

HSV infection can be confirmed using Tzanck test, viral culture, or PCR. Often, the condition is self-limiting and will resolve in a few weeks [6]. Treatment using antiretrovirals such as acyclovir should be initiated within 48 hours and can be effective in recurrent infections if started during the prodrome.

4. Conclusion

We understand that herpetic whitlow is rare and has always been a differential diagnosis for flexor sheath infection; however, in most cases, the absence of Kanavel’s signs and the presence of vesicles aid the diagnosis. Herpetic whitlow can present in atypical way and can mimic flexor sheath infection considerably, presenting with Kanavel’s signs, thus making the diagnosis more challenging. We emphasise the importance of detailed past medical history, careful clinical examination, and vigilant assessment of Kanavel’s signs as well as early consideration of viral cultures in recurrent cases.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Copyright

Copyright © 2014 Milos Brkljac et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Hand Infections: Background, Pathophysiology, Epidemiology

Author

Eden Kim, DO Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Eden Kim, DO is a member of the following medical societies: American College of Emergency Physicians, Council of Residency Directors in Emergency Medicine, Emergency Medicine Residents’ Association

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor – Chief Editor for Medscape.

Additional Contributors

Dan Danzl, MD Chair, Professor, Department of Emergency Medicine, University of Louisville Hospital

Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Gregory S Johnston, MD Assistant Professor of Emergency Medicine, Mount Sinai Beth Israel

Disclosure: Nothing to disclose.

Rohini J Haar, MD Staff Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center

Rohini J Haar, MD is a member of the following medical societies: Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Jordan Scaff, MD Resident Physician, Department of Emergency Medicine, Mount Sinai Beth Israel

Jordan Scaff, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents’ Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Amy K Rontal, MD, and Heatherlee Bailey, MD, to the development and writing of this article.

Kanavel signs of flexor sheath infection: a cautionary tale

INTRODUCTION

Hand infections are a common problem among the population and carry significant morbidity.^1,2 Deep hand infection such as flexor sheath infections are surgical emergencies and require prompt referral to prevent permanent disability. A misdiagnosis of flexor sheath infection can potentially lead to severe stiffness, deformity, or amputation of the digit.²

This article presents an unusual case of a 22-year-old with a chronic intermittent history of swelling and pain to the right middle finger (RMF). Although the history was slightly atypical, examination findings identified the Kanavel cardinal signs of tendon sheath infection (Figure 1).

Figure 1.

Flexor sheath infection of the right middle finger from a patient with a drill puncture wound.

CASE REPORT

A 22-year-old male left hand-dominant joiner presented to his GP with severe pain in the RMF. He was awoken the previous night by pain and swelling in his RMF. He was unable to attend work due to the severity of pain in his finger. The pain was constant, worse with movement, and relieved by analgesia (co-codamol and naproxen). He had no history of exacerbating factors, recent trauma, or systemic upset. He reported a glass injury to this finger 22 months previously.

He complained of several similar episodes of pain and swelling to the RMF over the past few years. These episodes usually lasted for 1–2 weeks then spontaneously self-resolved. This episode was more severe than previous episodes, which prompted him to seek medical advice from his GP. His past medical history included mild asthma managed with Qvar^® (beclometasone diproprionate) and salbutamol inhalers.

Examination revealed an RMF that was grossly swollen with tenderness on palpation of the flexor tendon from the distal palmar crease up to the distal interphalangeal joint and tenderness on passive extension. There was no heat or redness. He had a single callus over the proximal phalangeal joint of the RMF stemming from his occupation (the site of previous glass injury). He had normal vital signs and was afebrile.

Given his recurrent symptoms, atraumatic history, and increasing severity, his GP made an urgent outpatient referral (the authors’ trust currently aims to see urgent referrals within 2 weeks of referral) to the combined orthopaedic/plastic surgery hand team requesting physiotherapy review for this presumed severe intermittent tendonitis of the RMF. An on-call hand consultant was checking urgent referrals on the afternoon the referral arrived and noted a number of concerning features in a very well documented and thorough GP referral. A decision was made to contact the patient and ask him to attend the local emergency department immediately for a clinical review. Clinical examination confirmed the presence of all four Kanavel signs and he was diagnosed with an RMF flexor sheath infection. He received urgent intravenous flucloxacillin and was taken to the operating theatre the same evening, where exploration of the RMF revealed frank pus within the flexor sheath. This was washed out, and he remained an inpatient while he received 24 hours of intravenous antibiotics. Microbiology culture and sensitivity swabs were taken intra-operatively, which showed no growth of bacteria. He was discharged 2 days after admission with 5 further days of antibiotic therapy and referral to hand therapy to ensure good mobilisation of the digit.

DISCUSSION

Flexor sheath infections, also known as infected tenosynovitis, are a relatively common infection of the hand with a prevalence ranging from 2.5% to 9.4% of hand infections.³ If misdiagnosed, flexor sheath infections can lead to serious, life-threatening consequences. Digital flexor sheaths are a closed continuous synovial system that invest the flexor digitorum profundus and flexor digitorum superficialis (Figure 2). Flexor sheath infections are caused by direct inoculation due to trauma, contiguous spread from adjacent tissues, or via haematogenous spread. Common injuries include animal bites, puncture wounds, IV drug use, and wounds exposed to fresh/saltwater. Such injuries, if associated with severe tenderness, should raise a high suspicion of flexor tenosynovitis.⁴ Flexor sheath infections initially begin with exudative fluid within the tendon sheath, followed by the development of purulent fluid. Bacterial overgrowth within the synovial sheath leads to increased fluid and pressure, leading to ischaemia, and resulting in a septic necrosis of the tendon sheath and surrounding structures. If left untreated, complications may include soft tissue necrosis, osteomyelitis, and necrotising fasciitis. There are four cardinal signs of flexor tenosynovitis, which are also known as the Kanavel signs:

• an exquisite tenderness over the course of the sheath and limited to the sheath;

• the finger sits in a resting flexed posture;

• an exquisite pain on extending the finger, more marked at the proximal end; and

• a fusiform swelling of the whole finger.⁵

Figure 2.

Picture demonstrating the anatomical location and structure of the flexor sheath. Flexor sheath is composed of annular (ring) pulleys and cruciate (cross) pulleys. The pulleys are identified as A1, A2, C1, A3, C2, A4, C3, and A5.

The presence of all four Kanavel signs predicts a high sensitivity (91–97%) for flexor tenosynovitis.⁶ The earliest sign is often pain on passive extension,³ with a later sign being tenderness along the flexor sheath suggesting progression of the infection more proximally. Unlike most severe infections, fever is frequently absent (only 17%).³

Management of suspected flexor tenosynovitis in the community involves elevation to reduce swelling and urgent referral to the local hand surgery department. Inpatient management involves broad-spectrum antibiotic therapy and urgent surgery to debride tissues and irrigate the tendon sheath.³

This patient presented with an atypical history of RMF pain and swelling. A thorough examination by his GP revealed the Kanavel signs of flexor sheath infection and, although the diagnosis was not initially clear, the detailed referral raised the suspicions of the duty hand consultant who requested immediate surgical assessment and intervention.

In summary, flexor sheath infections are an important hand condition and all GPs should be aware of this condition and the potential consequences of missing these infections. The history may not always be typical, but if there are clinical features on examination, including the Kanavel signs, urgent same-day referral to a hand service should be considered.

POINTS OF INTEREST

• The Kanavel cardinal signs of flexor sheath infection are a finger held in slight flexion, fusiform swelling of the affected digit, tenderness along the flexor tendon sheath, and pain with passive extension of the digit.

• A suspicion of flexor sheath infection warrants urgent referral to a hand unit.

Acknowledgments

Thanks to Megan Anderson for creating and providing images.

Notes

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

Patient consent

The patient gave consent for publication of this case report.

Discuss this article

Contribute and read comments about this article: bjgp.org/letters

• Received November 24, 2018.
• Revision requested January 4, 2019.
• Accepted January 8, 2019.

• © British Journal of General Practice 2019

Finger Tip Injury – an overview

Anatomy and Pathology

Perionychium

The perionychium comprises the whole nail structure consisting of the nail bed (germinal and sterile matrix), nail plate, nail fold, eponychium, hyponychium, and paronychium (Fig. 31.2). The nail fold is the proximal depression into which the proximal nail fits. The nail fold has a dorsal roof (eponychium).^17,18,19 The lunula is the white arc seen at the base of the nail just distal to the eponychium. The highly vascularized nail bed shows through the nail and is normally pink in color.¹⁹ The hyponychium, between the nail bed and the distal nail, helps protect against fungal and bacterial contamination. The hyponychium contains leukocytes and lymphocytes that provide defense against invasion of the subungual area (under the nail). The paronychium is the lateral skin on the edge of the nail plate and bed.^17,18,19

The fingernail is important aesthetically as well as functionally. The nail provides counter-pressure against the finger when pinching or holding an object, which improves sensitivity. The fingernail protects, regulates temperature, and promotes dexterity.^17,18,19 In a traumatic fingertip injury, a subungual hematoma (confined mass of blood under the nail) may develop from bleeding underneath the nail plate. Bleeding separates the nail bed from the nail plate and can cause throbbing pain due to pressure. A hematoma can be evacuated by creating a hole in the nail. This procedure is performed by the physician.¹⁸

Paronychia

Paronychia refers to an infection of the soft tissue around the nail or nail plate (Fig. 31.3). It is the most common infection in the hand.^1,20 It may be acute or chronic. Hangnails, nail biting, or manicures are often the cause.^1,7,20,21 In children, paronychia is associated with thumb or finger sucking. Erythema, swelling, and pain may occur at the lateral fold or base of the fingernail.²¹ The most common causative organism of an acute paronychia is Staphylococcus aureus.^7,22

Chronic paronychia is more common in people who immerse their hands in water or detergents frequently, such as dishwashers and office cleaners.²³ Finger suckers and individuals with diabetes are more susceptible to chronic paronychias.²⁰ Normally, the hyponychium protects the subungual space from invading organisms. When the finger is repeatedly immersed in water and exposed to an alkaline environment, the protective barrier is violated and bacterial or fungal organisms enter more easily.¹⁸ It was previously believed that Candida albicans caused most chronic paronychias; however, these are now classified more as dermatitis caused by environmental irritants. Even though Candida albicans may be found, the fungus disappears when the physiological barrier is improved. It is more of an eczematous condition that responds better to steroids than antifungals.²³ Individuals with chronic paronychias suffer with repeated erythema and drainage. A decrease in vascularity of the nail fold due to recalcitrant inflammation may lead to separation of the nail fold from the nail plate.⁷ If the nail is not adequately treated, it may exhibit permanent deformity (Fig. 31.4).

Eponychia

When infection involves the tissue over the base of the nail in addition to one lateral fold beside the nail, it is more accurately called an eponychia. In an eponychia, pus develops near the lunula, the white arch visible at the base of some fingernails.²⁰ Due to inflammation at the base of the nail, a disruption of the seal between the nail fold and nail plate allows organisms to invade the tissue. An infection can begin on one side of the nail as a paronychia, then extend around the base to the opposite side of the nail, called a “run-around infection.”^1,14

Felon

An infection involving the distal finger pad is called a felon. The finger pad or pulp is divided into multiple compartments by fibrous septa. A subcutaneous abscess (pus) in these tiny compartments causes pressure, swelling, redness, and intense pain. A penetrating trauma, such as with splinters or finger-stick blood tests, can be the mechanism of injury.²¹ If left untreated, the abscess from the felon can extend into the distal phalanx and lead to osteomyelitis (inflammation of bone and marrow) or osteitis (inflammation of bone). The tip of the finger holds the highest concentration of sensory receptors in the hand,²⁰ so when pressure develops in the finger pulp, pain is usually severe.

Flexor Tendon Sheath Infection

The flexor tendons in the hand move within synovial sheaths. These sheaths are poorly vascularized and tendons receive much of their nutrition via synovial fluid diffusion.²⁰ Synovial fluid is an enticing environment for bacterial growth. When infection occurs within the sheath, a pyogenic flexor tenosynovitis (or purulent flexor tenosynovitis) develops.^14,21 Increased pressure from bacterial proliferation within the sheath leads to even less blood supply and can cause tendon necrosis and rupture. Flexor sheath infections are most commonly caused by Staphylococcus aureus and β–hemolytic Streptococcus.^20,21,24

Dr. Allen Kanavel, a pioneer in the treatment of hand infections in the early 20th century, described four signs (Kanavel cardinal signs) to identify pyogenic flexor tenosynovitis: (1) a semiflexed finger position, (2) uniform swelling of the finger, (3) tenderness along the tendon sheath, and (4) excruciating pain with passive extension of the finger.^{7,14,20,21,24}

Even when treated early, pyogenic flexor tenosynovitis can lead to permanent tendon scarring, residual digit stiffness, and lack of function.²⁵ Tendon necrosis or the spread of infection to deep fascial spaces can occur. Although uncommon, radial and ulnar bursal infections may occur in association with flexor tendon sheath infections of the thumb or small fingers. There may be tenderness and swelling at the distal wrist crease and along the hypothenar or thenar eminence in addition to the cardinal signs of Kanavel in either the small finger or thumb.²⁰

Clinical Pearl

Identify flexor tenosynovitis by the presence of four cardinal signs: (1) semiflexed finger position, (2) uniform swelling of the finger, (3) tenderness along the tendon sheath, and (4) excruciating pain with passive finger extension.^{7,14,20,21,24}

Deep Space Infection

Infection can develop in a number of spaces in the upper extremity (Fig. 31.5). These include the (1) thenar, (2) hypothenar, (3) midpalmar spaces in the hand, and (4) Parona’s space in the forearm (distal volar forearm deep to the flexor tendons). More superficial spaces are the (5) dorsal subcutaneous space, (6) dorsal subaponeurotic space, and (7) interdigital web spaces (collar-button abscesses occur here).^7,20 Infection may be caused by a penetrating injury or spread from an adjacent flexor tendon sheath infection.⁷ Clients may present with tenderness and swelling over the palmar spaces. Dorsal hand swelling is usually present, since the palm consists of tight fascia that limits the accumulation of swelling volarly. The presence of infection in the fascial spaces is a medical emergency and usually requires surgical drainage.^7,14,20

Osteomyelitis

Infection in the bone (osteomyelitis) can result when an infection is not eradicated in nearby soft tissue or if there is a penetrating trauma.^20,26 A felon, septic arthritis, soft-tissue infection, open fracture, or bite injury can lead to osteomyelitis. The most common pathogens are Staphylococcus aureus and Streptococcus, and immunocompromised clients are predisposed to these infections.⁷ Intact bone cortex provides a good barrier to penetration by pathogens, but trauma to the bone allows a pathway for infection. If local inflammation causes necrosis of the bone, called a sequestrum, pathogens can more easily live there due to the deficient vascularity. Antibiotics are less effective in areas of necrotic bone.²⁶

When hardware is required for fixation of a bone fracture, pathogens can enter the bone and an infection can develop around a pin or screw site (Fig. 31.6). Most pin tract infections are minor if treated with antibiotics and good wound care.²⁰ Incidence of pin tract infections is low, ranging from 0.5% to 21%.^{20,26,27,28,29} External fixation has a higher rate of infection than internal fixation.²⁹ Most infections from pins and screws are minor and do not lead to significant osteomyelitis if treated early. However, these infections can necessitate the early removal of hardware and can result in necrosis of the bone if the infection is not controlled.^20,26

Septic Arthritis

When infectious pathogens invade and colonize a joint, septic arthritis may occur. The presentation includes fusiform joint swelling (wider around the joint and tapered at both ends), erythema, and pain with movement of the joint. The most common pathogens are β-hemolytic Streptococcus and Staphylococcus aureus. Gout or other crystalline arthropathies have a similar clinical presentation, so cultures and crystal analysis can help with a more accurate diagnosis by the physician.⁷ Septic arthritis usually occurs after a penetrating injury or spreads from another infected area such as a felon or pyogenic flexor tenosynovitis.¹ Surgical drainage and intravenous (IV) antibiotics are the optimal course of treatment, but some physicians may initiate treatment with oral antibiotics.^7,30

Necrotizing Fasciitis

Necrotizing fasciitis is a serious medical emergency that requires emergent surgical debridement of necrotic tissue and IV antibiotics. Bacteria infect the fascia (connective tissue) and spreads quickly, destroying surrounding tissue. A delay in treatment can result in loss of limb or death. Most deaths stem from organ failure and sepsis. Mortality rates range from 23% to 76%.⁷ This serious bacterial infection, also known as the “flesh-eating infection,” is more common in immunocompromised individuals. Risk increases with diabetes, cancer, kidney disease, chronic liver disease, and IV drug abuse.^7,31 Symptoms can begin quickly but may be confusing, especially if a minor cut or injury is the cause. Individuals usually exhibit pain or erythema initially, and then they develop fever, fatigue, vomiting, and chills. Necrotizing fasciitis is fairly rare, but the Centers for Disease Control and Prevention estimates that there are at least 700 to 1100 cases each year in the United States.³¹

Everything You Need to Know

Middle finger joint pain is not always a simple thing as it can be a developing medical condition. Do you feel some hurt when you move your finger? Does the pain increase when you exert pressure on the finger?

In ordinary cases, middle finger joint pain when bending goes away after some days, but seek medical help if it persists. The resolution depends on the cause of the pain, so you must first identify the problem’s source.

Inflammation of the joints and trauma causes pain in the middle finger: psoriatic arthritis and rheumatoid cause middle finger joint pain around the knuckle and swelling.

Symptoms of Middle Finger Joint Pain

One of the most pronounced symptoms is swelling. The middle finger swells because of an accumulation of fluid in the body tissue. It is easy to notice if the finger is unwell because it will appear bigger than the others. However, sometimes the finger seems normal, without any swelling. In such instances, look out for the following symptoms;

• Visible deformity
• Pus on the finger
• Stiffness of the finger
• Skin pitting
• Wrist pain
• The affected area looks red
• Limited mobility
• Numbness
• Shiny or stretched skin
• Decreased grip strength
• Fingernail problems like bruising

Symptoms for severe finger pain symptoms that require immediate medical assistance include:

• Total or partial amputation of the middle finger
• High fever
• Uncontrolled bleeding
• Unbearable pain
• Immobile wrist or middle finger
• Visible deformity
• The finger feels numb

Main Causes

• Strain or sprain – Finger strains occur when the finger tendons or muscles stretch. A sprain is when the ligaments stretch or tear. Strains and sprains are common among athletes. The injury also happens when you fall and hurt your finger. The symptoms include instability of the joint, pain, slight immobility of the middle finger, swelling, and decoloration of the finger (if the injury is severe)
• Alcoholism
• Fractures – Each finger has three phalanges except the thumb. If any phalanges break, you experience numbness, limited mobility, bruising, swelling, and pain
• Abrasion
• Heavy metal poisoning such as lead poisoning
• An infection around your nail (paronychia)
• Finger dislocation – The finger experiences sharp shooting pain. In the case of a dislocation, the finger bones move from their original position. The dislocation is sometimes visible on the skin of the finger. The finger feels number and appears pale
• Blunt force injury such as dog bite
• Neuroma
• Metastases – It is common among cancer patients. The condition presents symptoms such as weakness in limbs and bone pain
• Degloving
• Arthritis – Rheumatoid arthritis affects the mobility and functionality of various body parts. The condition is autoimmune so, it can only be treated if it is diagnosed early. Some of the symptoms for pain in the middle finger joint include finger joint pain, stiffness, and swelling
• Bursitis – When the bursa sac is inflamed
• Neck injury (nerve-related injury)
• Underactive thyroid
• Boils – A boil is a bacterial infection that occurs around hair follicles. The infected follicle swells then pus develops in the area. If the infection is on the middle finger, it will swell, and there will be inflammation.
• Crush injury
• Raynaud’s disease
• Nerve compression or entrapment
• Ganglion cyst – A swelling or growth on top of a tendon or joint
• Deficiency in Vitamin B12

How to Diagnose Middle Finger Joint Pain

As discussed, the cause of pain in the middle finger determines the treatment. When you visit a doctor, they will examine the finger for any physical pain. If there is no visible symptom, they will recommend additional tests and ask further questions.

Provide precise answers to the questions that your doctor will ask you for an accurate diagnosis.

Questions to expect from your doctor:

• Show me where you feel the most pain on your finger
• Did you injure your finger?
• Which other symptoms are you experiencing besides swelling?
• Is the pain dull, sharp, burning, or tingling?
• Have you had recent exposure to frostbite or cold?
• Does this happen often? If yes, what medications do you take?
• Did you get a pedicure or manicure in the recent past?
• Does any other body part feel cold?

Doctors rely on X-ray and blood tests to diagnose middle finger Joint pain. If your doctor is not content with the X-ray results, he will request a nerve study(looks out for nerve dysfunction or damage) or additional imaging tests.

How to Treat Pain in the Middle Finger Pain

Home remedies are suitable for simple cases, but for severe pain or if the finger does not improve, you need to see a doctor. Here are the two main solutions for pain in the middle finger:

• Rheumatologic medications – The doctor may select one of the medicines for rheumatologic conditions to treat your finger.
• Antibiotics – If the cause of pain in the middle finger is due to bacterial infection, your doctor will recommend antibiotics.

Home Remedies

Not all middle finger Joint pain is severe; home remedies work well for a minor problem. However, if you experience extreme pain, see a doctor.

For home remedies, consider the following tips;

• Provide support to your middle finger by tapping it with a healthy one
• Remove any rings on the middle finger
• Ice cubes relieve pain so, put ice in a glass and dip your finger therein after every 15 minutes
• Massage the middle finger with ointment or counter irritant cream containing capsaicin or menthol
• Take pain killers like acetaminophen or ibuprofen
• Raise your finger and keep it still to prevent further swelling as a result of the accumulation of fluid
• Give your finger a break, do not engage the finger in strenuous activities

The source of pain in the middle finger determines if it is severe. However, if the finger does not respond well after home remedy treatment, see a doctor. Follow the treatment plan from your doctor to avoid complications due to pain in the middle finger. Some common complications include:

• Finger amputation
• Spread of infection to other areas
• Chronic disability
• Deformity of the finger
• Inability to perform daily tasks with your finger

Timely treatment can help alleviate complications. When the doctor examines your finger, provide the correct information, and take the medication as directed.

Severe pain in the middle finger is incapacitating, and it limits your ability to perform simple everyday tasks. If the pain is not attended to in good time, it can lead to severe complications. Seek care from a professional physiotherapist as soon as you realize that your finger has a problem.

Nail abnormalities | nidirect

Fingernail or toenail abnormalities are often a sign of infection or injury. They can sometimes be a sign of an underlying condition. See your GP if your nails have changed in colour, texture, shape or thickness and you don’t know why.

Brittle or crumbly nails

Brittle nails are often just a sign of ageing or long-term exposure to water or chemicals such as detergents and nail polish.

Wearing gloves will help protect your nails while doing work where your hands are exposed to water.

Regularly applying moisturising cream to your fingers and nails will also help protect them.

Sometimes, brittle or crumbly nails can be caused by:

• a fungal nail infection – this is often the cause of crumbly toenails and can be cleared by taking a course of antifungal tablets
• a skin condition called lichen planus – this can just affect the nails
• an underactive thyroid or overactive thyroid – where the thyroid gland either doesn’t produce enough hormones or produces too many
• nail psoriasis – a long-term skin condition that can cause the nails to become crumbly

Reactive arthritis is a less common cause of crumbly nails. It’s an unusual reaction of the immune system affecting the joints, muscles and other parts of the body following an infection.

Discoloured nails

The most common causes of a yellow nail are fungal nail infections or nail psoriasis.

Yellow nails can also be caused by any of the following:

• frequent application of nail varnish
• lymphoedema – a long-term condition that causes swelling of the skin
• permanent damage to your airways caused by bronchiectasis  – a long-term lung condition
• sinusitis – inflammation of the lining of the sinuses
• inflammation of the thyroid gland, found in the neck
• tuberculosis (TB) – a bacterial infection affecting the lungs
• jaundice (yellowing of the skin) – caused by liver disease
• some medications, such as mepacrine or carotene  
• chronic paronychia – infection of the nail fold

Green-black nails can be caused by overgrowth of bacteria called pseudomonas, particularly under loose nails.

It can be treated by applying antibiotic eye drops underneath the nails or soaking the affected nails in an antiseptic solution or vinegar.

Grey nails can be caused by medications such as antimalarials or minocycline.

Brown nails can sometimes be caused by:

Red or yellow drop under the nail

If the discolouration looks like a drop of oil under the nail or is the colour of salmon, you may have psoriasis of the nails.

Half white, half brown nails

Fingernails that are half white and half brown (brown near the tips) can be a sign of kidney failure, where the kidneys stop working properly.

It’s estimated up to 40 per cent of people with kidney failure have ’half-and-half’ fingernails. They also sometimes occur in people with AIDS and those who’ve had chemotherapy.

White nails

If most of the nail has turned white and it isn’t because it has become detached from the nail bed, it’s likely to be either a fungal nail infection or a sign of decreased blood supply to the nail bed, which causes something known as ’Terry’s nails’.

Terry’s nails are typically white with reddened or dark tips and can be a sign of a wide range of medical conditions, including:

Thickened, overgrown nails

A common cause of thickened nails is a fungal nail infection. This can also cause them to discolour and become crumbly (see above).

Other possible causes of thickened or overgrown nails are:

• psoriasis – a long-term condition that tends to also cause red, flaky patches of skin
• long-term pressure from shoes that are either too small or too narrow over the toes
• reactive arthritis – where the immune system attacks the joints, muscles and other parts of the body following an infection

Severely overgrown horn-like nails

Sometimes, the toenails become so overgrown and thickened that they resemble claws and are difficult to cut with conventional nail clippers.

This nail disorder, known as onychogryphosis (’ram’s horn nails’), is seen in older people or as a response to long-term pressure on the nails.

Regular chiropody can help, but sometimes the nails need to be removed by a podiatrist or doctor.

Loose nails

It’s normal for a toenail to come loose and fall off after an injury to the toe. Another common cause of a loose nail is over-manicuring the nails and cleaning underneath them with a sharp object.

Less commonly, a loose nail may be a sign of one of the following health conditions:

• a fungal nail infection
• psoriasis of the nail
• warts that cluster around the fingernail
• an overactive thyroid
• sarcoidosis – a condition where small clumps of cells form in the organs and tissues of the body
• amyloidosis – where protein builds up in the organs
• a problem with the connective tissue fibres in the body that support the organs and body tissues
• poor circulation – for example, caused by smoking or Raynaud’s phenomenon (a condition where the blood supply to the fingers and toes is affected, causing them to turn white) 
• an allergic reaction to medicine (usually to a type of antibiotic) or nail cosmetics

A loose nail should be cut back to where it’s detached to allow the nail to become reattached as it grows. You shouldn’t clean your nails with anything other than a soft nailbrush.

Indented spoon-shaped nails (koilonychia)

If your fingernails curve inwards like spoons (koilonychia), you may have one of the following disorders:

Pitting or dents on the nails

Pitting or small dents on the surface of your nails can be a sign of any of the following conditions:

• psoriasis
• eczema – a long-term skin condition that causes the skin to become itchy, red, dry and cracked 
• reactive arthritis
• alopecia areata – a condition that causes temporary bald patches on the scalp that are about the size of a large coin

Grooves across the fingernails (Beau’s lines)

Deep lines or grooves that go from left to right across the nail are known as Beau’s lines. They may occur as a result of:

• a previous illness – the line forms at the time of the illness 
• having chemotherapy
• a previous injury
• previous exposure to very cold temperatures, if you have Raynaud’s phenomenon

Illness, injury or cold temperatures can interrupt nail growth and cause nail grooves to form at the base of the nails.

The grooves tend to only be noticed a few months later. This is when the nails have grown and the grooves have moved up the nails to become visible.

It takes about four to six months for a fingernail to fully grow out. Six to 12 months for a toenail to fully grow out.

Unusually curved fingertips and nails

Clubbing of the fingertips means the tissue beneath the nails thickens and the fingertips become rounded and bulbous. The fingernails curve over the rounded fingertips.

Clubbing is thought to be caused by increased blood flow to the fingertips. It can run in families and be completely harmless.

If it suddenly develops, it may be a sign of one of many possible medical conditions, including:

White lines running across nails

White spots or streaks are normal and nothing to worry about. Parallel white lines that extend all the way across the nails, known as Muehrcke’s lines, are a sign of low levels of protein in the blood.

In contrast to Beau’s lines, they’re not grooved. They can occur as a result of liver disease or malnutrition.

Dark stripes running down the nail

Dark stripes running down the nails (linear melanonychia) are fairly common in black people over 20 years of age. In most cases it’s perfectly normal.

Dark stripes shouldn’t be ignored. This is because it can sometimes be a form of skin cancer that affects the nail bed, called subungual melanoma. It’s important that your doctor checks it to rule out melanoma.

Subungual melanoma usually only affects one nail. It will also cause the stripe to change in appearance. For example, it may become wider or darker over time and the pigmentation may also affect the surrounding skin (the nail fold).

Red or brown little streaks under the nails

If you have little red or brown streaks underneath your nails, it’s likely they’re splinter haemorrhages – lines of blood caused by tiny damaged blood vessels.

A few splinters under one nail are nothing to worry about. They are most likely caused by an injury of the nail.

If many nails are affected, the splinters may be a sign of lupus erythematosus, psoriasis, an infection of the heart valves (endocarditis) or another underlying condition.

A destroyed nail

Nails can be destroyed by:

• injury, including nail biting
• skin conditions, such as psoriasis or lichen planus
• overgrowth of the surrounding tissues, which is usually harmless –  for example, caused by a wart or verruca
• overgrowth of the surrounding tissues caused by skin cancer (this is rare)
• nail patella syndrome – a rare genetic condition which may cause missing nails, usually at birth 

See your GP if one of your nails is destroyed and you don’t remember injuring it.

Painful, red and swollen nail fold (paronychia)

Paronychia is inflammation of the nail fold (the skin and soft tissue that frames and supports the nail).

It’s most commonly caused by infection, injury or irritation.

Sometimes, it’s associated with an underlying skin condition, such as eczema or psoriasis, or another medical condition, such as diabetes or HIV.

Paronychia can develop over a few hours (acute paronychia). If it lasts for more than six weeks, it’s known as chronic paronychia.

Acute paronychia

Acute infective paronychia usually starts after a minor injury to the nail fold, such as from nail biting, picking or manicures.

The affected area is red, warm, tender and swollen. After a while, pus can form around the nail and may lift the nail.

Acute paronychia is often the result of a Staphylococcus infection.

Your GP will advise you of the best treatment. Treatment for acute paronychia includes antibiotic creams or tablets. If there’s a large amount of pus, surgically draining it can help. 

With treatment, an infected nail fold can clear up in a few days. If it isn’t treated or doesn’t respond to treatment, the problem can become long-term (chronic).

Chronic paronychia

Chronic paronychia often affects people who have their hands in water for long periods, or come into contact with chemicals, such as cleaners, bartenders, canteen staff or fishmongers.

It may start in one nail fold but can affect several fingers. The affected nail folds are swollen. They may be red and sore from time to time, often after exposure to water.

The nail plate gradually becomes thickened and ridged as it grows. It may become yellow or green and brittle.

See your GP if the condition is severe. They may prescribe antibiotic creams or tablets. In some cases, they may refer you to a dermatologist (skin specialist).

It can take months for chronic paronychia to clear. It can take up to a year after that for your nails to return to normal. Keeping your hands dry and warm,  using emollient hand cream often and not biting or picking your nails can help.

More useful links

The information on this page has been adapted from original content from the NHS website.

For further information see terms and conditions.

Don’t be so fast to shrug off “minor” cuts & punctures | 2017-07-01

You’ve seen plenty of occupational injury stats, here is one that’s startling: In 2012, workers suffered 186,830 nonfatal injuries to the hands and wrists serious enough to warrant days away from work, according to the U.S. Bureau of Labor Statistics. That’s 511 hand and wrist-related lost-time injuries every day of the year. This alone is enough to ensure you have a robust hand protection program.

Many of these serious hand and wrist injuries involve fractures, amputations, burns, carpal tunnel syndrome and tendinitis. But in 2014, BLS reports there were approximately 100,000 cuts, lacerations and punctures. These are the most likely everyday injuries to the hands- many times incurred by workers not wearing gloves. Many will require on-site first aid treatment and the worker goes back to the job. But think about it: Many more minor nicks, cuts and punctures to the hands will go unreported. Workers shake it off, maybe self-treat and put a bandage on the wound, thinking little of it.

A very close call

But consider the story of Chris Aldred, an IT specialist in Great Britain who cut his finger moving a computer, as reported in the London newspaper the Daily Mail. He didn’t give it a second thought. He said he had worse cuts from opening an envelope. But two weeks after his cut he felt a sharp twinge in his lower back. He also had a high temperature, felt hot and shivery, and had aches and pains – he assumed it was the flu. Three days later, Chris tried to get up to go to the bathroom in the middle of the night but was unable to move his legs. He was terrified.

An MRI scan revealed an eight-inch mass on his spine. The mass was an abscess. Doctors explained that Staphylococcus aureus bacterium, known for causing infections, had entered his body via a recent wound or cut. Doctors drained the abscess during surgery. It relieved the pressure on his spinal cord, but Chris remained paralyzed. It wasn’t clear if long-term damage had been caused. He was put on intravenous antibiotics to fight the remaining infection. Three days later, he felt confused, couldn’t stop shaking, and was sweating so much his bed sheets had to be changed. He had developed sepsis, caused when the body overreacts to an infection – his abscess. Sepsis attacks organs and tissues, causing a life-threatening drop in blood pressure and organ failure.

Every year, severe sepsis strikes more than one million Americans, according to the National Institute of General Medical Sciences. It’s estimated between 28 and 50 percent of these people die.

After five days of antibiotics, the infection was brought under control. Doctors warned of a slow recovery and couldn’t say if Chris would walk again. Within three weeks of his operation, he could wriggle his toes. With physiotherapy, he rehabbed slowly and was able to walk unaided five months after falling ill. Eighteen months after cutting his finger, Chris finally returned to work.

Injury or infection to a finger or fingers is a common problem, according to WebMD. Infection can range from mild to potentially serious. Often, infections start out small and are relatively easy to treat. But failure to properly treat these infections can result in permanent disability or loss of the finger- or in Chris Aldred’s case, something much worse.

Signs & symptoms of infection

Your workers should know that early recognition and proper treatment of finger cuts and punctures that become infected will help prevent most of the serious outcomes. Most infections are caused by bacteria. Symptoms vary widely. A burning or itching sensation may be present. There may be mild swelling. There also may be open wounds in the area affected occurring in clusters after the formation of a small blister-like lesion. The fluid in these lesions is usually clear in appearance but may be slightly cloudy. You may also have a low-grade fever and have swollen and tender lymph nodes in the area, according to WebMD.

If the motion of the fingers and hand is painful or difficult, this may indicate a deep space infection of some type. A deep space infection that arises in the web space of the fingers is also called a collar button abscess. The space between the fingers will be painful and swollen. The area may also be red and warm to the touch. As the abscess becomes larger, the fingers will be slightly spread apart by the increasing pressure. The central area may have a soft spot that represents a collection of pus under the skin, according to WebMD.

Don’t wait to see a doc

If any signs and symptoms are present, you should contact your doctor at once, according to WebMD. If you have signs or symptoms of a superficial infection or deep space infection, you should seek emergency care at once.

Another medical source, MedicineNet.com, which is reviewed by physicians, says if the wound begins to drain yellow or greenish fluid (pus), or if the skin around the wound becomes red, warm, swollen, or increasingly painful, a wound infection may be present and medical care should be sought. Any red streaking of the skin around the wound may indicate an infection in the system that drains fluid from the tissues, called the lymph system. This infection can be serious, especially if it is accompanied by a fever. Prompt medical care should be sought if streaking redness from a wound is noticed, according to MedicineNet.com

This medical source also states if you cannot control the bleeding from a cut or scrape (abrasion), seek medical attention. Any cut that goes beyond the top layer of skin or is deep enough to see into might need stitches, and should be seen by a doctor as soon as possible. Generally, the sooner the wound is sutured, the lower the risk of infection. Ideally, wounds should be repaired within six hours of the injury, according to MedicineNet.com

Puncture wounds do not usually bleed much, but treatment is necessary to prevent infection. A puncture wound can cause infection because it forces bacteria and debris deep into the tissue, and the wound closes quickly, forming an ideal place for bacteria to grow, according to MedicineNet.com

If and when you see a doctor, be ready to answer these questions, according to WebMD:

• How did the injury or infection start?
• When did this first occur or begin?
• Where did it occur? Home? Work? In water? In dirt? From an animal or human bite?
• Is it possible that a foreign body is in the wound?
• What have you done to care for this before seeing your doctor?
• When was your last tetanus shot?
• Any previous injuries to the area?
• Any other medical problems that you may have not mentioned?

Acute suppurative otitis media and brain abscess

O.V. Stratieva (From lectures for doctors)

Otogenic intracranial complications result from the penetration of infection from the ear cavities into the brain cavity. The number of patients with otogenic intracranial complications in relation to the total number of patients with diseases of the middle and inner ear ranges from 1 to 15% and tends to decrease. However, the problem of otogenic intracranial complications remains relevant.Over the past three years, we have operated on more than 30 patients with otogenic intracranial complications. The most common: thrombosis of the sigmoid and transverse sinuses, epidural abscess of the middle and posterior cranial fossa, perisinous abscess, otogenic meningitis, abscess of the temporal lobe of the brain, less often cerebellar abscess was observed. The features of the modern clinical picture of otogenic intracranial complications are characterized by a case from our practice.

Case from practice.

G., 68 years old, was admitted to the ENT center with complaints of headache, dizziness, nausea, weakness in the left leg, fever up to 37.5 ˚, malaise.

It is known that the patient was ill for a month when suddenly there were pains in the right ear and purulent discharge from the ear. She was treated independently, with dry heat. After two weeks, the condition improved. Ear pain and suppuration stopped. However, inadequacy, lethargy and headache appeared in the patient’s behavior, which forced the patient’s relatives to seek advice from an otolaryngologist.

On admission: the patient is conscious. There is no pain behind the ear.The eardrum is dull, no perforation, no pus. The neurologist found a deviation to the left with a finger – nasal test, flattening of the left nasolabial fold. In the fundus – atherosclerosis of the retinal vessels.

On a computed tomogram of the brain on the right in the temporoparietal region, extensive rounded formations with a capsule up to 2.1 cm in diameter, density from 19 to 24 H units, with contrast – up to 65 H units are determined. Additionally, magnetic resonance imaging was performed (Fig. 1 , 2), where a purulent process was established in the right temporal pyramid with a bifocal brain abscess and thrombosis of the cavernous sinus.

Otolaryngologists and neurosurgeons performed two operations: craniotomy with decompression of the brain, opening and removal of the temporal lobe abscess, and extended mastoidectomy with exposure of the cranial fossa and cerebral sinuses. During the operation, osteomyelitis of the temporal bone pyramid, the wall of the ear canal and the tympanic cavity was found. For four days the patient was in intensive care, then 14 days underwent rehabilitation at the ENT center, and after that she was discharged home in a satisfactory condition.

SUMMARY

Today, in comparison with the period from 1946 to 1980. XX century, the number of intracranial complications due to otitis media has significantly decreased. The use of powerful antibiotics has significantly improved the quality of treatment, but at the same time has made the diagnosis more difficult. If earlier manifest forms with vivid symptoms prevailed, then today, almost all otogenic intracranial complications develop secretly. Also, in recent years, the complexity of diagnosis is due to a combination of several forms of intracranial complications at once.

Urticaria, atopic dermatitis – what to do?

Often a person suffers from basic ignorance of the symptoms, types and methods of allergy treatment. Currently, more than 30% of the world’s population suffers from allergies and its varieties. How to deal with this disease?

Elena Vladimirovna Saranyuk, an allergist of the State Budgetary Healthcare Institution “DGP No. 105”, will help us to understand this.

– Elena Vladimirovna, what is urticaria? What are the characteristic manifestations of this disease?

– Urticaria is a group of diseases characterized by the development of blisters or angioedema, it is classified by the duration of the course, by types and subtypes.Acute urticaria lasts up to 6 weeks, chronic for more than 6 weeks. Urticaria is allergic, idiopathic (caused by exposure to low or high temperatures), dermographic, vibration, cholinergic, contact, etc.

Allergic urticaria is mild (less than 20 blisters up to 24 hours), moderate (up to 50 blisters up to 24 hours) and intense (more than 50 blisters up to 24 hours).

Intense urticaria is characterized by places with merging blisters, severe itching, possible fever, and the development of angioedema.

Diagnosis of urticaria does not require laboratory confirmation. An extended diagnostic examination is carried out in patients with long-term, recurrent urticaria. Chronic urticaria is more common in middle-aged women, less common in children (only 5% of patients are children under 16 years of age). It is characterized by an undulating course without progressive deterioration; in 50% of patients, spontaneous remission occurs.

– What are the causes of this disease?

– The cause of urticaria can be autoimmune thyroiditis, viral infections, hepatitis, bacterial infections, parasitic infestations, non-infectious chronic inflammatory processes (gastritis, cholecystitis), nonspecific food hypersensitivity, autoimmune diseases.Only in 15-20% of cases of urticaria is it possible to clearly identify the causes of the disease. In 95% of cases, acute urticaria is self-limited within two weeks and is effectively treated with 2nd generation antihistamines. In most cases, acute urticaria remains the only episode in a patient’s life.

– What is the treatment?

– The patient receives rational drug therapy. The patient should follow a hypoallergenic diet with the exclusion of suspected allergens, avoid conditions under which overheating of the body occurs: too warm clothes, excessive physical activity, the use of hot foods and drinks.In the case of dermographic urticaria, you need to give up tight clothing, carrying heavy loads, and long hikes. For solar urticaria, avoid direct exposure to the sun and wearing open clothing. With cold urticaria – hypothermia, exclude swimming in reservoirs.

– What is atopic dermatitis?

– This is an allergic skin disease that usually occurs in early childhood in people with a hereditary predisposition to this disease.The probability of atopic dermatitis in children of healthy parents is up to 20%. In the presence of a burdened history of allergies in one of the parents, the probability of the disease can be up to 50%, in both – 80%. Atopic dermatitis is characterized by itching, in 5% of cases it is not allergic. It is classified by the age periods of the disease: infant (up to 2 years old), children (2-13 years old), adolescent and adult (over 13 years old), as well as the stages of the disease: exacerbation – remission and the prevalence and severity of the process.

The infant period is characterized by the predominance of the exudative form with manifestations of hyperemia, edema, oozing, crusts, characteristic localization in the area of ​​the outer surface of the legs, flexion and extensor surfaces of the limbs, neck.

The period of childhood is characterized by rashes, peeling, thickening of the skin, increased skin pattern, scratching, hypo- or hyperpigmentation, localized in the flexor surfaces of the joints, neck, behind the ear region.

The adolescent (adult) form is characterized by the manifestation of infiltration, hyperemia with a bluish tinge, localized in the upper half of the body, face, neck, and upper extremities.

Atopic dermatitis may eventually disappear completely, acquire a mild course or take a chronic recurrent course with exacerbations.

In 70% of patients with a severe form of the disease, bronchial asthma subsequently develops.

Patients with manifestations of atopic dermatitis need to undergo an allergic examination during remission to clarify the nature of the disease in order to eliminate inflammation, itching, avoid secondary infection, and improve the quality of life.

Arpimed

If you are pregnant, nursing or intending to have a baby, consult your doctor or midwife before using Clotrimazole.

If you have already told your doctor or midwife, follow their instructions carefully.

Important information about the ingredients in Clotrimazole

How to take Clotrimazole

If Clotrimazole solution has been prescribed for you by your attending physician, follow the structure prescribed in IN .

If you bought the drug without a prescription, follow these instructions:

• If the feet are affected, wash and dry thoroughly before applying the solution, especially between the toes.
• For skin infections, Clotrimazole should be applied in a thin layer evenly to the affected area, two or three times a day.
• A few drops are sufficient to treat a palm-sized surface.
• For ear infections, inject 2 to 3 drops of Clotrimazole solution into the ear two or three times a day.
• Treatment should be continued for at least two weeks after all signs of infection have cleared to prevent re-infection.
• If you suffer from athlete’s foot fungal infection, the parallel use of antifungal powder is effective. Please consult your doctor or pharmacist on this matter.

Symptoms of infection, such as itching or pain, should disappear after a few days of treatment, although symptoms such as redness and scaling may persist for a longer period and take time to disappear completely.If symptoms persist, see your doctor.

Clotrimazole solution is for external use only:

Do not use the solution in the mouth or swallow it.

If you accidentally swallow the solution, notify your doctor immediately or contact the nearest hospital emergency room.

In case of accidental contact with eyes or mouth, rinse with water and consult a doctor if necessary.

If you forgot to apply the next dose of Clotrimazole solution:

It is necessary to apply the solution as soon as possible, and then return to the usual scheme of application.

Your treatment will be effective if you follow these simple guidelines:

• Although the affected area is usually itchy, try to refrain from scratching. Scratching can damage the surface of the skin and further spread the infection.
• The affected skin must be kept clean.
• Pay particular attention to dry skin, but avoid excessive rubbing.
• Do not use towels, bath mats or cleaned utensils with other people, as this may spread infection (contamination).
• Always wash your hands after each treatment, as this will prevent it from spreading.

If you have athlete’s foot fungal infection:

• Remember to always dry thoroughly between your toes.
• Thoroughly wash socks, stockings and tights in hot water to remove any skin debris or fungal spores.
• Change your shoes daily, if possible.

Tick-borne infections | Ministry of Health of the Kaliningrad Region

Tick-borne infections – diseases transmitted to humans and animals through tick bites.
Several hundred thousand patients visit doctors of various specialties for tick bites every year.
Ixodid ticks are a source of increased danger, since after sucking they can infect a person not only with tick-borne encephalitis, but also with ixodic tick-borne borreliosis (Lyme disease), ehrlichiosis, anaplasmosis, tularemia and other infectious diseases.
The Kaliningrad region is endemic for such tick-borne infections as tick-borne borreliosis (Lyme disease), viral tick-borne encephalitis. The epidemic season lasts about 7-8 months (from April to October).
Lyme disease (tick-borne systemic borreliosis) is an infectious disease characterized by lesions of the skin, joints, nervous system, heart, often taking on a chronic, recurrent course.
Carriers of the causative agent of the disease are ixodid ticks, which are widespread in the wooded areas of our region. The favorite habitat of ticks is shrubs, tall grass and larch trees. Ticks retain the pathogen for life and can transmit it to their offspring.
Sources of infection – murine rodents (voles, small hamsters), large ungulates (elk, deer, farm animals). The main route of transmission of infection to humans is through the saliva of an infected tick. The disease is more common in the spring-summer and summer-autumn periods. The incubation period (from the moment the pathogen gets in to the onset of symptoms of the disease) ranges from 3 days to 3 months (an average of 3 weeks).
Tick-borne encephalitis is a severe viral disease of the nervous system.
Infection with tick-borne encephalitis is possible through the bite of a tick stuck to the body or by eating raw milk from sick goats and cows. Ticks can attack humans at any time of the day or night during spring and all summer. Once on clothes, ticks move over the places where the skin is thinner: behind the ears, on the neck, in the armpits, in the groin areas, etc.
Symptoms. The disease most often begins with severe headache, weakness, tinnitus, chills, vomiting, a sharp rise in temperature to 38-39 degrees.The severity of the disease increases over several days, complete or partial paralysis of the muscles of the arms, shoulder girdle, neck appears, which can remain for life. In severe cases, there are violations of speech, swallowing, sometimes death occurs.
Prevention of tick-borne infections
Effective protection against tick-borne encephalitis – preventive vaccinations. They are held during the autumn-winter period. Vaccinations are carried out for individuals of certain professions working in areas with encephalitis or traveling to them (students of construction teams, tourists, geological prospectors, gas pipeline workers, etc.)).
There is no vaccine against tick-borne borreliosis.
The easiest way to prevent tick-borne encephalitis is to follow strict tick-borne rules. It is necessary to tuck trousers into boots or boots, a shirt into trousers, sleeve cuffs should fit snugly to the wrists, and the collar should be tightly buttoned. It is better to tie the head with a scarf, tightly covering the ears and neck. Rubber boots significantly reduce the possibility of ticks crawling on clothing.
During your stay in nature, you need to periodically carefully inspect your clothes and remove attached ticks.When settling down for lunch and rest, choose a cleared, grubbed area. You cannot rest on freshly cut branches, under old tree cuts, in the grass. Returning from the forest, it is necessary, without entering the room, to take off your outerwear and examine it. Then check for ticks on your body. The mites you find are best burned. Do not crush ticks with your fingers, as touching the mucous membrane of the nose or eyes with contaminated hands can lead to infection with tick-borne encephalitis.
Having found a sucked tick, you need to immediately or within the first day contact the clinic at your place of residence.There the tick will be removed, and you will be prescribed the necessary prophylaxis. If it is impossible to remove the tick in the clinic, you can contact the emergency room for children or adults.
For laboratory testing of ticks, you can contact the laboratory of the FBUZ “Center for Hygiene and Epidemiology in the Kaliningrad Region” from 8-30 to 15-30 daily from Monday to Friday at the address: Kaliningrad, Kosmicheskaya st.