Herpetic Whitlow

Aka: Herpetic Whitlow

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II. Definitions

  1. Herpetic Whitlow
    1. Herpes Simplex Virus infection of the finger tip

III. Causes

  1. Herpes Simplex Virus I Infection (Oral Herpes)
    1. Most common in children due to autoinoculation from Oral Herpes
  2. Herpes Simplex Virus II Infection (Genital Herpes)
    1. Most common in adults

IV. Mechanism

  1. Herpetic infection via broken skin
  2. Herpetic Whitlow may recur via dormancy in the dorsal root Ganglion

V. Risk Factors

  1. Children with active Herpes Gingivostomatitis
  2. Women with Genital Herpes
  3. Healthcare workers
  4. Immunocompromised patients

VI. Symptoms

  1. Incubation Period: 2 to 20 days
  2. Initial outbreak
    1. Single digit (typically a finger) with Blisters, pain, itching and swelling
    2. Fever
  3. Recurrent outbreak
    1. Localized mild burning and itching may precede recurrence by up to 2-3 days

VII. Signs

  1. Vesicles over an erythematous base (appear after symptom onset above)
    1. Contain clear fluid which may become opaque and clouded over time
    2. May coalesce into bullae over 2 weeks
    3. Forms ulcer with hemorrhagic base
  2. Lymphadenopathy
    1. Epitrochlear Lymphadenopathy
    2. Axillary Lymphadenopathy
  3. Course
    1. Resolves spontaneously in 3 to 4 weeks
    2. Recurs in 20 to 50% of cases
      1. Recurrence is usually more mild than initial event

VIII. Differential Diagnosis

  1. See Hand Infection
  2. Felon
  3. Acute Paronychia
  4. Cellulitis
  5. Tuft Fracture
  6. Dyshydrotic Eczema

IX. Labs

  1. Not indicated in most cases where the diagnosis is clear (clinical diagnosis is the norm)
  2. Diagnostic testing when indicated (obtaining fluid from lanced Vesicle)
    1. Tzanck Smear
    2. Viral culture
    3. HSV PCR

X. Management

  1. Avoid lancing lesions (aside from diagnostic testing)
    1. Lancing increases the risk of Bacterial superinfection
  2. Prevent transmission
    1. Keep lesion bandaged
    2. Keep bandages dry
  3. Antiviral Agents
    1. Herpetic Whitlow is self limited and resolves spontaneously without treatment
      1. Antivirals if started within 48 hours may shorten course and reduce viral shedding
    2. Indications
      1. Recurrent infection
      2. Immunocompromised status (risk of disseminated HSV)
      3. Consider in first 48 hours to shorten course
    3. Agents
      1. Acyclovir 400 mg orally 3 times daily for 7 days (adult dose)
      2. Famciclovir (Famvir)
      3. Valacyclovir (Valtrex)

XI. Complications

  1. Bacterial superinfection (Staphylococcus Aureus, Streptococcus Pyogenes)
    1. Impetigo or Cellulitis
    2. Skin Abscess
    3. Osteomyelitis

XII. References

  1. Antosia in Marx (2002) Rosen's Emergency Medicine, 530
  2. Cory in Mandell (2000) Infectious Disease, p. 1569-71
  3. Goparaju and White (2025) Crit Dec Emerg Med 39(9): 15-6
  4. Clark (2003) Am Fam Physician 68:2167-76 [PubMed]
  5. Rerucha (2019) Am Fam Physician 99(4):228-36 [PubMed]

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