Treatment of Herpetic Whitlow
Oral antiviral therapy with acyclovir, valacyclovir, or famciclovir should be initiated immediately upon diagnosis of herpetic whitlow, with treatment duration of 7-10 days for first episodes. 1
First-Line Treatment Regimens
The CDC recommends three equally effective oral antiviral options for 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 be started as soon as possible after diagnosis, as early initiation improves outcomes 1. If healing is incomplete after 10 days, extend therapy until clinical resolution 1.
Critical Treatment Principles
Avoid surgical incision or drainage - herpetic whitlow is self-limited and does not require surgical intervention unless a secondary bacterial abscess develops 2, 3. This distinguishes it from bacterial felon or paronychia, where incision and drainage would be appropriate 3.
Do not use topical antivirals - topical therapy is substantially less effective than systemic treatment and is not recommended 1. Oral or intravenous routes are required for adequate therapeutic effect 1.
Special Populations and Circumstances
Immunocompromised Patients
Higher antiviral doses are necessary for immunocompromised individuals 1:
- Acyclovir 400 mg orally 3-5 times daily until clinical resolution 1
- For severe cases: IV acyclovir 5 mg/kg every 8 hours 1
- If lesions persist despite acyclovir, suspect resistance and consider foscarnet 40 mg/kg IV every 8 hours 1
Recurrent Episodes
For patients experiencing recurrent herpetic whitlow, two management strategies exist 1:
Episodic therapy (start at first sign of prodrome):
- 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):
- Acyclovir 400 mg orally twice daily 1
- Valacyclovir 250 mg orally twice daily, or 500-1000 mg once daily 1
- After 1 year of continuous suppression, consider discontinuation to reassess recurrence rate 1
Secondary Bacterial Infection
If a bacterial abscess develops concurrently with herpetic whitlow, surgical drainage may be performed in conjunction with IV acyclovir and appropriate antibiotics 2. This represents the only scenario where surgical intervention is appropriate 2.
Patient Management Essentials
- Prevent transmission: Patients must avoid contact with lesions to prevent autoinoculation or spread to others 1
- Monitor for complications: If symptoms worsen despite treatment, consider secondary bacterial infection or antiviral resistance 1
- Expect natural course: Untreated infections typically resolve in approximately 3 weeks, though treatment accelerates healing significantly 4, 5
Common Pitfalls to Avoid
The most critical error is performing surgical incision on a herpetic whitlow mistaking it for a bacterial infection 3. The presence of painful vesicles on an erythematous base, rather than purulent drainage, should guide you toward the correct diagnosis 3. Confirmation can be obtained via Tzanck test or viral culture if diagnosis is uncertain 3.