What is the recommended treatment for herpetic whitlow?

Treatment of Herpetic Whitlow

For herpetic whitlow, oral antiviral therapy with acyclovir 400 mg three times daily for 5 days is the recommended first-line treatment. 1

First-Line Treatment Options

Herpetic whitlow is a herpes simplex virus infection of the digits that presents with pain, tingling, burning, swelling, erythema, and vesicles. The following oral antiviral medications are recommended for treatment:

• First-line options:
  • Acyclovir 400 mg orally three times daily for 5 days 1
  • Acyclovir 200 mg orally five times daily for 5 days 1
  • Acyclovir 800 mg orally twice daily for 5 days 2
  • Famciclovir 125 mg orally twice daily for 5 days 1
  • Valacyclovir 500 mg orally twice daily for 5 days 2

Treatment Algorithm

1. Initial episode:

   • Begin antiviral therapy as soon as possible after symptom onset
   • Complete the full 5-day course even if symptoms improve
   • Assess response within 72 hours of starting treatment 1

2. For recurrent episodes:

   • Initiate treatment at the first sign of prodrome or lesions
   • Same dosing regimens as initial episode
   • Consider suppressive therapy if ≥6 recurrences per year 1

3. For frequent recurrences (≥6 per year), suppressive therapy options:

   • Acyclovir 400 mg orally twice daily 1
   • Famciclovir 250 mg orally twice daily 1
   • Valacyclovir 250 mg orally twice daily 1
   • Valacyclovir 500 mg or 1000 mg orally once daily 1

Special Considerations

• Immunocompromised patients: May benefit from topical acyclovir for chronic, ulcerative lesions when systemic therapy is not desired 3
• Severe infections: Consider intravenous acyclovir for 7-10 days 3
• Renal impairment: Dose adjustments required, especially for valacyclovir 1

Important Clinical Pearls

• Early treatment is crucial to reduce pain, speed healing, and shorten viral shedding duration 1
• Herpetic whitlow can be misdiagnosed as bacterial flexor tenosynovitis due to similar presentation, including positive Kanavel's signs 4
• The infection is self-limiting but typically takes about three weeks to resolve without treatment 5
• After initial infection, the virus remains latent in nerve tissue and can reactivate, suggesting lifelong infection 5

Patient Education

• Advise patients about the natural history of the disease and potential for recurrent episodes 1
• Counsel about risk of viral transmission and need to avoid contact when lesions or prodromal symptoms are present 1
• Inform healthcare workers that this is an occupational hazard and emphasize preventive measures 5

Follow-up

• Monitor for complete resolution of lesions 1
• Watch for complications such as secondary bacterial infection 1
• For patients on suppressive therapy, reassess after one year to evaluate continued need 2