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HERPETIC WHITLOW

Introduction

Herpetic whitlow is an intensely painful viral infection of the hand affecting at least one finger, typically localized to the finger or thumb tip. In ~60% of cases, herpes simplex virus 1 (HSV-1) is the cause; in the remaining 40% of cases, herpes simplex virus 2 (HSV-2) is the causal factor. Patients under the age of 20 are usally infected with HSV-1 while older patients maybe infected with either HSV-1 or HSV-2.3  Adamson first described herpetic whitlow in 1909.  In 1959, it was noted to be an occupational risk among health care workers.  Herpetic Whitlow is a clinical diagnosis but the diagnosis should be confirmed by a Tzank test and by viral cultures which are the most specific evidence for the diagnosis. 3,4

Incidence and Related Conditions

  • In the United States, the estimated annual incidence is 2.4-5.0 cases per 100,000 population; men and women are equally affected
  • The thumb and index finger are the most commonly affected digits
  • Healthcare workers with history of exposure to oral/genital secretions are at increased risk
  • Some toddlers and preschool children who engage in thumb- or finger-sucking behavior are at increased risk if they have herpes labialis or herpetic gingivostomatitis
  • Lymph node enlargement and red streaking on the forearm can occur.

Differential Diagnosis

  • Cellulitis
  • Felon finger
  • Paronychia
ICD-10 Codes

  • HERPETIC WHITLOW

    Diagnostic Guide Name

    HERPETIC WHITLOW

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    HERPETIC WHITLOWB00.89   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Herpetic Whitlow Left Thumb
  • Herpetic Whitlow Left Thumb. Note classic vesicles (arrows)
    Herpetic Whitlow Left Thumb. Note classic vesicles (arrows)
Symptoms
Pain
Swelling
Erythema
Vesicular lesions
Typical History

The typical patient is a health care work such as a nurse in the ICU or a dentist. These workers and any others with repeated exposure to patients' oropharynx are at increased risk for Herpetic Whitlow.  Young children represent a second at risk group.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Control symptoms
  • Shorten the course of infection
  • Avoid secondary infections
  • Avoid complications
Conservative
  • Self-limiting disease
  • Incision and drainage is contraindicated
  • Antiviral therapy for symptomatic relief

–  Acyclovir (oral/topical)

–  Famciclovir (oral)

–  Valacyclovir (oral)

–  Penciclovir (topical)

  • Antibiotic treatment only in cases complicated by bacterial superinfection4
  • Tense vesicles may be unroofed to help ameliorate symptoms

Wedge resection of fingernail to help ameliorate symptoms in cases involving the subungual space can be consider after starting antiviral medications.

Operative

NOT INDICATED!

Complications
  • Recurrence
  • 30-50% of patients report hyperesthesia or numbness between episodes of reactivation
  • Scarring, ocular spread
  • Encephalitis which has been reported after attempted surgical incision and drainage.4
Outcomes
  • Excellent outcome in uncomplicated cases; spontaneous resolution in 3-4 weeks
Key Educational Points
  • Other terms used to describe herpetic whitlow include: aseptic felon, herpes febrilis of the finger, herpetic paronychia and recurrent traumatic herpes infection.
  • The Tzank test can help support the diagnosis of Herpetic Whitlow by identifying multinucleated giant cells but this test is not specific for Herpetic Whitlow only. Also false negatives do occur.
  • Viral cultures are the most accurate way to confirm the diagnosis of Herpetic Whitlow.
  • Incision and drainage of a secondary bacterial abscess should only be done after starting antiviral medications.
References

Cited Articles

  1. Shiyovich A, Nesher L. Atypical presentation of herpetic whitlow as dark brown vesicles in a hyperbilirubinemic patient. Infection 2014 ePub. PMID: 25066415
  2. Arora R, Chattopadhyay S, Agrawal S, Chatterjee S.Self-inflicted herpetic whitlow. BMJ Case Rep 2014 ePub. PMID: 24729108 
  3. Rubright JH, Shafritz AB. The herpetic whitlow. J Hand Surg Am 2011;36(2):340-2. PMID: 21186084
  4. Hurst LC, Gluck R, Sampson SP, Dowd A. Herpetic Whitlow with bacterial abcess. J Hand Surg AM 1991; 16A: 311-314.

Reviews

  1. Sanders JE, Garcia SE. Pediatric herpes simplex virus infections: an evidence-based approach to treatment.Pediatr Emerg Med Pract 2014;11(1):1-19. PMID: 24649621
  2. Rubright JH, Shafritz AB. The herpetic whitlow. J Hand Surg Am 2011;36(2):340-2. PMID: 21186084

Classics

  1. Louis DS, Silva J Jr. Herpetic whitlow: herpetic infections of the digits. J Hand Surg Am 1979;4(1):90-4. PMID: 759512
  2. Berkowitz RL, Hentz VR. Herpetic whitlow--a non-surgical infection of the hand. Plast Reconstr Surg 1977;60(1):125-7. PMID: 20607955
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