What is the treatment for herpetic whitlow (herpes on the hand)?

Treatment for Herpetic Whitlow (Herpes on the Hand)

Oral antiviral therapy with acyclovir, valacyclovir, or famciclovir is the recommended treatment for herpetic whitlow, with the infection typically being self-limiting and resolving in approximately three weeks without surgical intervention. 1, 2

First-Line Treatment Options

Oral antiviral medications are the most effective treatment approach:

• Valacyclovir 2g twice daily for 1 day is the preferred first-line option, offering the most convenient dosing schedule 3, 4
• Famciclovir 1500mg as a single dose is an equally effective alternative with simplified dosing 3, 4
• Acyclovir 400mg five times daily for 5 days is another option but requires more frequent dosing 3, 4

Critical Timing Considerations

Early initiation of therapy is essential for optimal outcomes:

• Treatment should begin within 24 hours of symptom onset, ideally during the prodromal phase (pain, tingling, burning) 3, 4, 1
• Peak viral titers occur in the first 24 hours after lesion onset, making early intervention crucial for blocking viral replication 3, 4
• Patient-initiated episodic therapy at first symptoms may even prevent lesion development in some cases 3

What NOT to Do: Critical Pitfalls

Avoid surgical intervention unless absolutely necessary:

• Herpetic whitlow is self-limiting and surgical exploration should generally be avoided 2, 5
• Surgical intervention can be confused with flexor tenosynovitis when Kanavel's signs are present, leading to unnecessary procedures 2
• One case required three surgical washouts before HSV-2 was identified and properly treated with acyclovir, highlighting the importance of correct initial diagnosis 2

Do not rely on topical antivirals:

• Topical antivirals provide only modest clinical benefit and are significantly less effective than oral therapy 3, 4
• Topical application cannot reach the site of viral reactivation in nerve tissue 3, 6

Management of Recurrent Herpetic Whitlow

For patients with frequent recurrences (≥6 episodes per year), suppressive therapy is indicated:

• Valacyclovir 500mg once daily (can increase to 1000mg once daily for very frequent recurrences) 3, 4
• Famciclovir 250mg twice daily 3
• Acyclovir 400mg twice daily 3
• Daily suppressive therapy reduces recurrence frequency by ≥75% 3, 4
• Acyclovir has proven effective as suppressive therapy for herpetic whitlow specifically 1

Special Populations and Resistant Cases

Immunocompromised patients require special consideration:

• Episodes are typically longer and more severe in immunocompromised patients 3, 6
• Higher doses or longer treatment durations may be required 3, 4
• Resistance rates to acyclovir are higher (7% vs <0.5% in immunocompetent patients) 3

For acyclovir-resistant HSV infection:

• IV foscarnet 40mg/kg three times daily is the treatment of choice 3, 7
• Consider resistance if lesions fail to respond to multiple standard antiviral regimens 7
• Repeat PCR testing may be necessary if initial testing is negative but clinical suspicion remains high 7

Supportive Care Measures

Symptomatic treatment can provide additional relief:

• Topical anesthetics for pain management 6, 4
• OTC analgesics and antipyretics 6
• White soft paraffin ointment applied every 2 hours during acute illness 4
• Antiseptic rinses (1.5% hydrogen peroxide or 0.2% chlorhexidine) to reduce bacterial colonization 4

Prevention and Occupational Considerations

Healthcare workers are at high risk and should take precautions:

• Use gloves when handling secretions from patients' mouths and respiratory tracts 1, 5
• Avoid patient care when active lesions are present 5
• Appropriate isolation of patients with herpes infections 5
• The virus establishes latency in nerve tissue, creating a reservoir for potential lifelong recurrence 1

Diagnostic Confirmation

When diagnosis is uncertain:

• Tzanck test, viral culture, or PCR can confirm HSV-1 or HSV-2 infection 2, 7, 5
• Repeat testing may be necessary if initial results are negative but clinical suspicion remains 7
• Distinguish from bacterial flexor tenosynovitis, which may present similarly with Kanavel's signs 2