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Anatomy
Anatomy
Illustration by Dr. Lisa Bryski
Herpetic whitlows are caused by the Herpes Simplex virus. They classically occur in the distal fingertip but can occur anywhere on hand.1
classic presentation
classic presentation
3
Patients may present with pruritis, and /or intense burning pain at site followed eventually by erythema and vesicles.
Their exam demonstrates erythema followed by small vesicular rash. Vesicles may coalesce to form bullae which will then crust over and lead to ulceration.
Occasional malaise, fever and lymphadenitis.
Children may present with associated gingivostomatitis.
diagnosis
diagnosis
2
The diagnosis is primarily clinical with visualization of the classic vesicular eruption. Unlike bacterial infections the pulp space is often not tense.
To confirm the diagnosis:
Polymerase chain reaction (PCR)
main method of confirmation at most sites
Other historical tests for HSV include:
Tzanck smear
Direct fluorescent antibody testing
Viral culture (several days)
Antibody titers (several weeks)
Tip: Remember when obtaining a sample for PCR you must sample the vesicle fluid and use a viral medium. Only perform if the vesicles are popped or burst - do not debride due to significant risk of superinfection.
Management
Management
Whitlows are self-limiting therefore non-operative observation +/- acyclovir is the standard of care.
Patients should be reminded that this is contagious and that an occlusive dressing decreases the chance of transmission.
Discharge care should include:
Anticipate resolution in 7-10 days
The whitlow may reoccur with fever, stress, sun exposure.
Contact precautions
Operative management with surgical debridement NOT indicated and is associated with significant comorbidity including superinfections, encephalitis, death.
references
references
Kimberlin, D. (Unknown Year). Herpes Simplex Virus. Retrieved from http://www.do-super.com.tw/v30.asp
Yaeen, A., Ahmad, Q. M., Farhana, A., Shah, P., & Hassan, I. (2015). Diagnostic value of Tzanck smear in various erosive, vesicular, and bullous skin lesions. Indian dermatology online journal, 6(6), 381–386.
Hoff, N. P., & Gerber, P. A. (2012). Herpetic whitlow. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 184(17), E924.
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