What is the treatment protocol for herpetic whitlow?

Treatment Protocol for Herpetic Whitlow

For herpetic whitlow, oral antiviral therapy with acyclovir, valacyclovir, or famciclovir is the recommended first-line treatment and should be initiated as soon as possible after diagnosis. 1, 2

First-Line Treatment Options

• Acyclovir 400 mg orally three times a day for 7-10 days 1
• Acyclovir 200 mg orally five times a day for 7-10 days 1
• Famciclovir 250 mg orally three times a day for 7-10 days 1
• Valacyclovir 1 g orally twice a day for 7-10 days 1

Treatment Considerations

• Treatment may be extended if healing is incomplete after 10 days of therapy 1
• Herpetic whitlow is self-limiting but typically resolves in about three weeks; antiviral therapy speeds healing and decreases viral shedding and pain 2, 3
• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1, 4
• Early recognition and treatment is crucial to prevent complications and unnecessary interventions 5

Special Populations

Immunocompromised Patients

• Higher doses may be required for immunocompromised patients 1
• Acyclovir 400 mg orally three to five times a day until clinical resolution 1
• For severe cases, intravenous acyclovir 5 mg/kg every 8 hours may be required 1
• If lesions persist during acyclovir treatment, resistance should be suspected 1
• For acyclovir-resistant strains, foscarnet 40 mg/kg IV every 8 hours until clinical resolution is an alternative 1

Diagnostic Pitfalls

• Herpetic whitlow can mimic bacterial infections such as paronychia, felon, or flexor tenosynovitis 5, 6
• Even with positive Kanavel's signs (suggesting flexor tenosynovitis), consider herpetic whitlow in the differential diagnosis 6
• Misdiagnosis can lead to unnecessary antibiotic therapy or surgical intervention 5
• Characteristic findings include:
  • Pain, tingling, and burning of the affected digit 3
  • Swelling and vesicles on an erythematous base 3
  • Honeycomb-like vesicular lesions with minimal drainage 5

Patient Education

• Advise patients that herpes simplex virus remains latent in nerve tissue after initial infection 3
• Recurrences suggest the infection persists for life 3
• Patients should avoid contact with the lesions to prevent autoinoculation or transmission 1
• For healthcare workers, herpetic whitlow is an occupational hazard that can be prevented with proper precautions 3

Follow-up Recommendations

• Monitor for complete resolution of lesions 4
• For recurrent episodes (more than 6 per year), consider suppressive therapy with daily antivirals 2
• If symptoms worsen despite treatment, consider secondary bacterial infection or resistance 5, 1