What is the treatment for herpetic whitlow?

Treatment of Herpetic Whitlow

Herpetic whitlow should be treated with oral acyclovir 200 mg five times daily for 7-10 days or until clinical resolution is attained, similar to the treatment approach for first clinical episodes of herpes simplex virus infections. 1

What is Herpetic Whitlow?

Herpetic whitlow is a herpes simplex virus infection of the digits of the hand, caused by either HSV-1 or HSV-2. It presents with:

• Pain, tingling, and burning of the distal phalanx as initial symptoms 2
• Swelling and vesicles on an erythematous base 2, 3
• Self-limiting infection typically resolving in about three weeks 2

The infection occurs through direct inoculation (exogenous or autogenous) or reactivation of latent virus, and is considered an occupational hazard for healthcare professionals who have contact with patients' oral secretions 2, 4.

Diagnosis

Accurate diagnosis is crucial to distinguish herpetic whitlow from bacterial infections like felon or paronychia, as the management differs significantly:

• Clinical presentation of painful vesicular lesions on an erythematous base 3
• Laboratory confirmation through:
  • Viral culture (most definitive) 1
  • HSV DNA PCR (most sensitive) 1
  • HSV antigen detection 1
  • Tzanck test 3, 4

Treatment Approach

First Clinical Episode

• Oral acyclovir 200 mg five times daily for 7-10 days or until clinical resolution 1
• Alternative: Acyclovir 400 mg orally 5 times a day for 10 days (particularly for more severe cases) 1

Recurrent Episodes

When treatment is initiated during the prodrome or within 2 days of onset:

• Acyclovir 200 mg orally 5 times a day for 5 days, or 1
• Acyclovir 400 mg orally 3 times a day for 5 days, or 1
• Acyclovir 800 mg orally 2 times a day for 5 days 1

Severe Disease Requiring Hospitalization

For severe cases or in immunocompromised patients:

• Intravenous acyclovir 5-10 mg/kg body weight every 8 hours for 5-7 days or until clinical resolution 1

Special Considerations

Immunocompromised Patients

• May require more aggressive therapy 1
• Higher risk of prolonged episodes with extensive disease 1
• May develop acyclovir-resistant strains requiring alternative antiviral agents 1

Important Caveats

• Surgical incision is not indicated and may worsen the condition 3, 5
• Topical acyclovir is substantially less effective than oral therapy and is not recommended 1
• Acyclovir neither eradicates latent virus nor affects subsequent risk, frequency, or severity of recurrences 1
• Patients should avoid activities that might spread the virus while lesions are present 1

Prevention

• Use of gloves when handling secretions or having contact with oral or genital lesions 4
• Healthcare workers with active lesions should avoid direct patient care 4
• Appropriate isolation of patients with herpes infections 4

Common Pitfalls

• Misdiagnosis as bacterial infection leading to inappropriate surgical intervention 6, 3
• Delayed recognition can lead to complications including superinfection 5
• Confusion with flexor tenosynovitis, especially when Kanavel's signs are present 6

Herpetic whitlow is a self-limited infection, but early recognition and appropriate antiviral therapy can reduce the duration of symptoms and potentially decrease the risk of complications or transmission.