What is the recommended treatment for herpetic whitlow?

Treatment of Herpetic Whitlow

The recommended first-line treatment for herpetic whitlow is oral antiviral therapy with acyclovir, valacyclovir, or famciclovir, which should be initiated as soon as possible after diagnosis. 1

First-Line Treatment Options

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

Treatment Considerations

• Treatment may need to be extended if healing is incomplete after 10 days of therapy 1
• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1, 2
• Herpetic whitlow is self-limiting, typically resolving in about three weeks, but antiviral treatment speeds healing and decreases viral shedding and pain 3, 2
• Surgical incision is contraindicated for uncomplicated herpetic whitlow as it may worsen the condition and delay healing 4

Special Populations

Immunocompromised Patients

• Higher doses of antiviral therapy are required for immunocompromised patients 1:
  • Acyclovir 400 mg orally three to five times a day until clinical resolution 5
  • For severe cases, intravenous acyclovir 5-10 mg/kg every 8 hours until clinical resolution 5, 1
• If lesions persist during acyclovir treatment in immunocompromised patients, resistance should be suspected, and alternative treatments such as foscarnet may be considered 1

Recurrent Episodes

For patients with recurrent herpetic whitlow:

• Episodic therapy: Start treatment at the first sign of prodrome or lesions 5

  • Acyclovir 400 mg orally three times a day for 5 days, OR
  • Acyclovir 200 mg orally five times a day for 5 days, OR
  • Acyclovir 800 mg orally twice a day for 5 days, OR
  • Famciclovir 125 mg orally twice a day for 5 days, OR
  • Valacyclovir 500 mg orally twice a day for 5 days 5

• Suppressive therapy (for frequent recurrences - six or more per year):

  • Acyclovir 400 mg orally twice a day, OR
  • Famciclovir 250 mg orally twice a day, OR
  • Valacyclovir 250 mg orally twice a day, OR
  • Valacyclovir 500-1000 mg orally once a day 5

Complications and Pitfalls

• Herpetic whitlow can be mistaken for bacterial felon or paronychia, leading to inappropriate surgical intervention 4
• In rare cases, herpetic whitlow may be complicated by secondary bacterial infection requiring both antiviral and antibiotic treatment 6
• Positive Kanavel's signs (traditionally indicating flexor tenosynovitis) can sometimes be present in herpetic whitlow, leading to diagnostic confusion 7
• After 1 year of continuous suppressive therapy, consider discontinuation to assess the patient's rate of recurrent episodes 5

Patient Education

• Advise patients to avoid contact with the lesions to prevent autoinoculation or transmission 1
• Inform patients that the virus remains latent and may recur 3
• Counsel patients to seek treatment early during recurrences for maximum benefit 2