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 Treatment Approach
The CDC recommends oral antiviral therapy as the cornerstone of treatment, which should be started as soon as possible after diagnosis 1. The three equivalent first-line options are:
- 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 duration may be extended beyond 10 days if healing remains incomplete 1. While herpetic whitlow can be self-limiting and resolve without intervention in approximately three weeks, antiviral therapy significantly accelerates healing and reduces viral shedding 2, 3.
Critical Treatment Considerations
Avoid topical antiviral therapy—it is substantially less effective than systemic treatment and is not recommended. 1, 4 This is a common pitfall, as topical acyclovir has minimal efficacy compared to oral regimens 4.
Do not perform surgical drainage or incision. 5 Herpetic whitlow is frequently misdiagnosed as bacterial paronychia or felon, leading to unnecessary surgical intervention that prolongs morbidity and increases complications 6, 5.
Special Populations and Severe Cases
Immunocompromised Patients
Higher antiviral doses are required for immunocompromised patients 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, 7
A case report documented successful treatment of acyclovir-resistant herpetic whitlow in an HIV-positive patient using foscarnet after multiple standard antiviral regimens failed 7.
Recurrent Episodes
For patients experiencing recurrent herpetic whitlow 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 suppressive therapy, consider discontinuation to reassess recurrence frequency 1.
Patient Management Essentials
Instruct patients to avoid contact with lesions to prevent autoinoculation or transmission to others. 1 This is particularly important for healthcare workers, as herpetic whitlow is an occupational hazard 3, 6.
Monitor for complete lesion resolution 1. If symptoms worsen despite treatment, consider secondary bacterial infection (which can coexist with viral infection) or antiviral resistance, and adjust treatment accordingly 1, 6.