Intended for healthcare professionals

Endgames Picture Quiz

Painful blisters on the hand

BMJ 2013; 346 doi: (Published 26 March 2013) Cite this as: BMJ 2013;346:f1753
  1. Yuliya Velykoredko, year 3 medical student1,
  2. David N Adam, dermatologist and assistant professor at the University of Toronto2
  1. 1Faculty of Medicine, University of Toronto, Toronto, ON, Canada
  2. 2Department of Medicine, Division of Dermatology, St Michael’s Hospital, Toronto, ON, Canada, M5B 1W8
  1. Correspondence to: D N Adam david.adam{at}

A 74 year old previously healthy man presented to the emergency department with acute onset of pain and swelling in the right hand. Earlier that evening he had played a game of recreational ice hockey. He did not have a fever and was otherwise well. He had not experienced trauma during the game and his medical history was unremarkable. Physical examination showed large lesions on the right hand (figs 1 and 2).

Fig 1 Volar view of the right hand

Fig 2 Dorsal view of the right hand


  • 1 What do the images show?

  • 2 What is the diagnosis and what differential diagnoses should be considered?

  • 3 What are the most likely organisms responsible for the condition?

  • 4 What is the appropriate management?


1 What do the images show?

Short answer

Figure 1 shows large tense bullae with surrounding erythema sparing the index finger. The blisters extend proximally to the metacarpophalangeal joints and affect the volar and dorsal aspects of the fingers (figs 1 and 2).

Long answer

It is important that the skin lesions and their distribution are correctly identified to establish a working differential diagnosis in this case. Well circumscribed, raised, and fluid filled lesions can be classified as vesicles or bullae, depending on size. Vesicles are defined as being less …

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