Physical Signs and Symptoms
  • Involved finger is often exquisitely tender and quite edematous; however, in contrast to a felon, the pulp space usually is not tensely swollen.
  • Examination usually reveals the characteristic grouped vesicular lesions or ulcers with surrounding erythema.
  • Fluid within the vesicles is usually clear, although it may appear cloudy or hemorrhagic.
  • Extension of infectious process into subungual space may be observed.
  • Lymphangitic streaking and possibly adenopathy of the epitrochlear and axillary nodes may be found.
  • Preexisting herpetic lesions may be noted in oral cavity or genitals.

Mode of Infection
  • As noted, health care workers are at risk due to possibility of exposure to virus-containing secretions from their patients.
  • Patients with other herpetic lesions, such as herpes labialis, herpetic gingivostomatitis, or genital herpes, are at risk due to autoinoculation.
  • Immunocompromised patients are at risk for primary infection, reactivation, and possibly systemic complications.

Laboratory Studies

  • Diagnosis of herpetic whitlow usually is clinical, based on presentation of the affected digit with characteristic lesions and a typical history.
  • In children, observation of concurrent gingivostomatitis is almost pathognomonic.
  • In adults, the presence of occupational risk factors or finding of concurrent oral or genital herpes lesions should strongly suggest the diagnosis.
  • Definitive diagnostic testing includes the Tzanck test, viral cultures, serum antibody titres, fluorescent antibody testing, or DNA hybridization.
    • In the Tzanck test, smears are obtained by scraping the base of an unroofed vesicle. Smears are Giemsa stained, and a positive test is indicated by light microscopy findings of multinucleated giant cells, often with visible viral inclusions.
    • Viral culture of the aspirated vesicle fluid is the most sensitive assay, but this test is usually more costly and time consuming, requiring 24-48 hours.
    • Serum antibody titres are usually cost prohibitive, as are fluorescent antibody testing and DNA hybridization, which are not commonly available.

Emergency Department Care:

  • Herpetic whitlow is a self-limiting disease. Treatment is mostly directed toward symptomatic relief.
  • Tense vesicles may be unroofed to help ameliorate symptoms, and wedge resection of the fingernail may be used for the same purpose in cases involving the subungual space.
  • Deep surgical incision is contraindicated, since this may lead to delayed resolution, bacterial superinfection or systemic spread, and complications such as herpes encephalitis.

Follow up Care

  • Advise routine outpatient follow up care to ensure resolution of infection and to monitor for evidence of bacterial super infection.

In/Out Patient Medicines

  • Include analgesics in the treatment of herpetic whitlow.
  • Antivirals may be of benefit in primary infections.
  • In cases of super infection, antibiotics are effective against skin pathogens.

Deterrence/Prevention

  • Avoidance of exposure is the key to prevention of herpetic whitlow.
    • Health care workers should use gloves, practice strict hand washing, and scrupulously observe universal fluid precautions.
    • Studies have demonstrated herpes virus in 2.5% of asymptomatic patients and in 6.5% of hospitalized patients with tracheostomies.
  • Patients with oral, labial, or genital lesions and the parents and caregivers of children with lesions should be cautioned against digital contact with lesions.
  • Complications usually are minimal provided that the affected patients are immunocompetent.
  • Misdiagnosis as a bacterial paronychia or felon with resultant deep incision may lead to delayed resolution, increased risk of bacterial superinfection, systemic spread (rare), and possibly development of herpes encephalitis.
  • Hyperesthesia or numbness has been reported in 30-50% of patients between episodes of reactivation.
  • Other potential complications include scarring of the affected digit and ocular spread.

Prognosis

  • Prognosis is excellent in uncomplicated cases, with spontaneous resolution in 3-4 weeks.

Patient Education

  • Advise patients of the likelihood of future recurrence and warn of the possibility of disease spreading to other parts of the body and to other individuals.

Medical/Legal Pitfalls

  • Misdiagnosis and inadvertent deep incision may result in delayed healing, increased risk of bacterial superinfection or systemic spread, and possibly herpes encephalitis.

Herpetic whitlow is an infection of the finger by the herpes simplex virus (HSV). Herpetic whitlow is typically caused by HSV-1, the type that generally causes oral herpes. Herpes can infect any site on the skin, but the finger is probably the most common. Children newly infected with oral herpes can spread it to their thumbs during sucking. In adults, it also can be spread from an oral lesion, almost always after a primary (new) infection rather than recurrences.

Health care workers such as dental hygienists frequently develop herpetic whitlow after caring for patients with oral herpes. A person infected with HSV can transmit it to others even if he or she has no active lesions, so you may have contracted it from any one of your patients. This infection is just one more reason to wear gloves with every single patient.

Unlike oral and genital herpes, which the infected person can transmit even when he or she has no visible lesions, herpetic whitlow probably is less likely to spread in the absence of lesions. One is probably contagious as long as one has a wet, open lesion. Since it is only on the finger, it is probably not infectious as long as gloves are worn. Herpetic whitlow can recur, though usually not as often as do oral or genital herpes.

As far as a baby is concerned, herpetic whitlow in the mother is not really a cause to worry too much. It is genital herpes that causes most of the problems for newborns. Women who become infected shortly before delivery and have genital lesions at the time of delivery are most likely to transmit the infection to the baby, although individuals with recurrent herpes lesions also can infect the baby during delivery.

Far less common is infection during pregnancy, long before delivery. Infection of the fetus can result in stillbirth and congenital anomalies. Most of the data on transmission to the fetus involve genital herpes, not oral herpes.

How the Infection Develops

After an incubation period of 2 to 14 days, the patient may experience prodromal symptoms, such as fever and malaise. Common initial symptoms of infection include tingling pain or tenderness in the affected digit, followed by throbbing pain, swelling, and redness. Vesicles, which form over the next week, contain fluid that may be clear, bloody, or cloudy. While these vesicles are present, herpetic whitlow is extremely contagious.

About 2 weeks after vesicles first appear, a crust forms over them. This signals the end of viral shedding.

If untreated, the infection usually resolves in 3 to 4 weeks. Treatment with antiviral medication may speed healing and reduce viral shedding, but some patients never regain full sensitivity or range of motion in the digit.

Herpetic whitlow vesicles are susceptible to secondary bacterial infections. Signs and symptoms of a secondary infection include fever, chills, red streaks the length of the arm, lymphadenopathy, and fatigue.

After healing, about 20% to 50% of the patients experience recurrences, which may be triggered by trauma, febrile illness, disease, or other physiologic changes. The recurrence usually is milder and clears up faster than the original infection.

The health care provider will base her diagnosis on signs and symptoms and confirm it with lab testing Options include isolating the virus from a sample of vesicular fluid, a Tzanck test (a stain histology test), and serum immunoglobulin antibody testing for HSV IgM (to detect acute HSV) and IgG (to detect a history of HSV).

Treatment and Prevention

To treat herpetic whitlow, the health care provider will order an oral, topical, or I.V. antiviral medication. These medications accelerate healing, reduce viral shedding and pain, and may help prevent a recurrence. Prescriptions for secondary infection may be given, if indicated. Incision and drainage of vesicles isn't indicated because this may spread the infection.


FAQ's for Herpetic Whitlow
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Finger Herpetic Whitlow Picture

Finger Herpetic whitlow picture

Symptoms caused by HSV 1 infection (HSV 1 is known to affect the following areas of the body.)

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