Treatment of Herpetic Whitlow
Initiate oral antiviral therapy immediately upon diagnosis with acyclovir 400 mg three times daily, valacyclovir 1 g twice daily, or famciclovir 250 mg three times daily for 7-10 days. 1
First-Line Antiviral Regimens
The CDC recommends three equally effective oral antiviral options for treating herpetic whitlow 1:
- Acyclovir 400 mg orally three times daily for 7-10 days 1
- Valacyclovir 1 g orally twice daily for 7-10 days 1
- Famciclovir 250 mg orally three times daily for 7-10 days 1
Treatment should begin as soon as possible after diagnosis to maximize effectiveness 1. If healing remains incomplete after 10 days, extend therapy until complete resolution 1.
Critical Treatment Considerations
Avoid topical antiviral therapy—it is substantially less effective than systemic treatment and is not recommended. 1 This is a common pitfall, as topical acyclovir has minimal efficacy compared to oral regimens 2.
Do not perform surgical incision or drainage, as this can lead to viral dissemination, superinfection, and complications 3. Herpetic whitlow is often misdiagnosed as bacterial paronychia or cellulitis, leading to unnecessary antibiotics or surgical intervention 4, 3.
Special Populations
Immunocompromised Patients
Higher antiviral doses are required for immunocompromised individuals 1:
- Acyclovir 400 mg orally three to five times daily until clinical resolution 1
- For severe cases: Intravenous acyclovir 5 mg/kg every 8 hours 1
- If lesions persist despite acyclovir treatment, suspect resistance and consider foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1
Recurrent Episodes
For patients experiencing recurrent herpetic whitlow, two management strategies exist 1:
Episodic therapy (start at first sign of prodrome or lesions) 1:
- Acyclovir 400 mg orally three times daily for 5 days 1
- Valacyclovir 500 mg orally twice daily for 5 days 1
Suppressive therapy (for frequent recurrences) 1:
- Acyclovir 400 mg orally twice daily 1
- Valacyclovir 250 mg orally twice daily, or 500-1000 mg orally once daily 1
After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 1.
Patient Education and Monitoring
Instruct patients to avoid contact with lesions to prevent autoinoculation to other body sites or transmission to others 1. Healthcare workers with herpetic whitlow should avoid patient contact until lesions have completely healed 5.
Monitor for complete lesion resolution 1. If symptoms worsen despite appropriate antiviral therapy, consider secondary bacterial infection or antiviral resistance and adjust treatment accordingly 1, 4.