What is the most likely diagnosis and acute management for a 30‑year‑old woman who develops sudden painful, swollen hands immediately after drinking alcohol?

Acute Gout Flare Triggered by Alcohol

This presentation is most consistent with an acute gout attack precipitated by alcohol consumption, and you should immediately treat with NSAIDs, low-dose colchicine, or intra-articular corticosteroids while strongly counseling complete alcohol cessation. 1, 2

Diagnosis

The combination of sudden painful, swollen hands immediately following alcohol intake in a young woman strongly suggests acute gout. 1, 3

• Alcohol—particularly beer—is a well-established and potent trigger for acute gout flares, with risk increasing in a dose-dependent manner starting at 5+ drinks over 48 hours 1, 2
• The effect occurs rapidly, typically within 24 hours of consumption 2
• Hand involvement (proximal and distal interphalangeal joints, wrists) is characteristic of gout, though less common than foot involvement initially 1, 4
• Chronic alcoholics can experience gout attacks at lower serum urate levels (mean 7.7 mg/dL) compared to non-alcoholics (mean 10.1 mg/dL), making diagnosis more challenging 5

Key Diagnostic Features to Confirm

• Rapid onset of severe pain reaching maximum intensity within 6-12 hours 3
• Joint swelling, erythema, and exquisite tenderness 3
• Serum uric acid >6.8 mg/dL (though may be lower during acute attack, especially in drinkers) 3, 5
• Joint aspiration showing monosodium urate crystals under polarized microscopy is definitive 6

Acute Management

First-Line Pharmacotherapy

Choose one of three equally effective options based on patient contraindications: 6, 1

• NSAIDs: Most convenient first-line option when no contraindications exist (avoid in heart failure, renal impairment, GI bleeding risk) 6, 1
• Low-dose colchicine: 0.5 mg three times daily (total 1.8 mg/24h) is as effective as high-dose regimens with significantly fewer adverse effects; preferred when NSAIDs contraindicated 6, 1
• Intra-articular corticosteroids: Highly effective for monoarticular hand involvement—aspirate joint first, then inject 1

Alternative Options

• Oral or intramuscular glucocorticoids are as effective as NSAIDs with similar safety profiles 6
• Paracetamol can serve as adjunct analgesia but not primary therapy 6

Critical Pitfalls to Avoid

Do NOT initiate urate-lowering therapy (allopurinol, febuxostat) during the acute attack—this will worsen and prolong symptoms. 1

• High-dose colchicine (4.8 mg/24h) offers no additional benefit over low-dose (1.8 mg/24h) and causes significantly more adverse effects 6, 1
• Do not use superglue or occlusive bandages on inflamed joints 6

Immediate Lifestyle Intervention

Counsel complete alcohol avoidance during the acute attack and substantial long-term reduction, with particular emphasis on eliminating beer. 1

• Beer poses the greatest gout risk due to high purine content 1
• All alcoholic beverages can trigger attacks; even moderate consumption precipitates flares in susceptible individuals 1, 2
• This carries the highest strength of recommendation in management guidelines 1

Long-Term Management Plan

If this is a second gout attack within one year, initiate urate-lowering therapy after the acute episode resolves: 1

• Target serum uric acid <360 µmol/L (6 mg/dL) 1
• Start allopurinol at low dose and titrate gradually 6
• Provide prophylactic colchicine 0.5-1 mg daily when starting urate-lowering therapy to prevent early flares 1
• Address comorbidities: hypertension, hyperlipidemia, obesity, chronic kidney disease 1, 3

Alternative Diagnosis Consideration

If symptoms do not improve within 48-72 hours of appropriate gout treatment, consider:

• Allergic contact dermatitis from alcohol-based hand sanitizers or cleaning products (though timing immediately after drinking makes this less likely) 6
• Septic arthritis (requires urgent joint aspiration for culture) 7

However, the temporal relationship to alcohol consumption and bilateral hand involvement make acute gout the overwhelmingly most likely diagnosis 1, 2.