herpetic whitlow

Herpetic whitlow

Herpetic whitlow also known as digital herpes simplex, finger herpes, or hand herpes, is a painful herpes simplex virus (HSV) infection occurring on the fingers or around the fingernails. Herpetic whitlow is usually seen in children who suck their thumbs and adolescents and young adults following genital herpes exposure 1). In children, herpetic whitlow tends to co-occur with gingivostomatitis aphthosa. Infections with HSV (herpes simplex virus) are very contagious and are easily spread by direct contact with infected skin lesions. Oral secretions are usually a source of infection, so, among adults, health care workers (medical or dental) who are exposed to patients’ oral mucosa while not wearing gloves and athletes engaging in contact sports (e.g., rugby players or wrestlers) are at risk for viral exposure 2). Herpes simplex virus infection usually appears as small blisters or sores around the mouth, nose, genitals, and buttocks, though infections can develop almost anywhere on the skin. Furthermore, these tender sores may recur periodically in the same sites.

There are 2 types of HSV: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). HSV-1 infections usually occur around the mouth, lips, nose, or face, while HSV-2 infections usually involve the genitals or buttocks. However, HSV-1 can sometimes cause infections in the genitals or buttocks, while HSV-2 can occasionally cause infections around the mouth, lips, nose, or face.

Both types of HSV produce 2 kinds of infections: primary and recurrent. Because it is so contagious, the herpes simplex virus causes a primary infection in most people who are exposed to the virus. However, only about 20% of people who have a primary infection with the herpes simplex virus actually develop visible blisters or sores. Appearing 2–20 days after a person’s first exposure to HSV, the sores of a primary infection last about 1–3 weeks. These sores heal completely, rarely leaving a scar. Nevertheless, the virus remains in the body, hibernating in nerve cells.

Certain triggers can cause the hibernating (latent) virus to wake up, become active, and travel back to the skin. These recurrent herpes simplex virus infections may develop frequently (every few weeks), or they may never develop. Recurrent infections tend to be milder than primary infections and generally occur in the same location as the primary infection.

People develop herpetic whitlow when they come into contact with areas already infected with HSV, either on their own bodies or on someone else’s body. Usually, there is a break in the skin, especially a torn cuticle at the base of the fingernail, which allows the virus to enter the finger tissue and establish an infection. HSV-1 causes approximately 60% of herpetic whitlow infections, while HSV-2 causes the remaining 40%.

Herpetic whitlow can affect people of all ages, of all races, and of both sexes. However, it is more common in children and in dental and medical workers. Children often contract herpetic whitlow as a result of thumb- or finger-sucking when they have a herpes infection of the lips or mouth. Dental and medical workers may contract herpetic whitlow by touching the contagious lesions of a patient with herpes simplex virus infection. In these groups of people—children and health care workers—herpetic whitlow is most commonly caused by HSV-1. In everyone else, herpetic whitlow is usually caused by infection with HSV-2.

Herpetic whitlow should be distinguished from other infectious diseases (e.g., bacterial whitlow) because of the different treatments required 3). There is no cure for herpes simplex virus infection. Antiviral medication has been widely accepted as effective in reducing the duration of symptoms in primary infection and in recurrent episodes. However, there are no controlled studies showing the optimal doses of antiviral agents for treating herpetic whitlow 4).

Untreated herpes simplex virus infections will go away on their own, but medications can reduce the symptoms and shorten the duration of outbreaks.

Figure 1. Herpetic whitlow

Footnote: (A) Swelling and redness with grouped vesicular lesions and pustulation on the right forefinger of a 14-month-old girl. (B) The patient also presented with gingivitis and stomatitis, appearing as vesicles with a red halo and discrete ulcers on her lower lip and tongue.

[Source 5) ]

Figure 2. Herpetic whitlow finger

herpetic whitlow finger

Is herpetic whitlow contagious?

Yes. Infections with herpes simplex virus (HSV) are very contagious and are easily spread by direct contact with infected skin lesions. Because herpes simplex virus infections are very contagious, it is important to take the following steps to prevent spread (transmission) of the virus during the prodrome phase (burning, tingling, or itching) and active phase (presence of blisters or sores) of herpetic whitlow:

  • Avoid sharing towels and other personal care items
  • Cover the affected finger with a bandage
  • Wear gloves if you are a health care provider
  • Don’t pop any blisters—it may make the condition worse

Unfortunately, the herpes simplex virus can still be transmitted even when someone does not have active lesions. However, this is very unusual for patients with herpetic whitlow.

Herpetic whitlow causes

Herpetic whitlow is caused by one of two types of herpes simplex virus (HSV), members of the Herpesvirales family of double-stranded DNA viruses 6).

  • Type 1 HSV is mainly associated with oral and facial infections
  • Type 2 HSV is mainly associated with genital and rectal infections (anogenital herpes)

However, either virus can affect almost any area of skin or mucous membrane.

After the primary episode of infection, HSV (herpes simplex virus) resides in a latent state in spinal dorsal root nerves that supply sensation to the skin. During a recurrence, the virus follows the nerves onto the skin or mucous membranes, where it multiplies, causing the clinical lesion. After each attack and lifelong, it enters the resting state.

During an attack, the virus can be inoculated into new sites of skin, which can then develop blisters as well as the original site of infection.

Primary attacks of Type 1 HSV infections occur mainly in infants and young children. In crowded, underdeveloped areas of the world, nearly all children have been infected by the age of 5. In less crowded places, the incidence is lower; for example, less than half of university entrants in Britain have been infected. Type 2 HSV infections occur mainly after puberty and are often transmitted sexually.

HSV is transmitted by direct or indirect contact with someone with active herpes simplex, which is infectious for 7–12 days. Asymptomatic shedding of the virus in saliva or genital secretions can also lead to transmission of HSV, but this is infrequent, as the amount shed from inactive lesions is 100 to 1000 times less than when it is active. The incubation period is 2–12 days.

Minor injury helps inoculate herpes simplex virus (HSV) into the skin. For example:

  • A thumb sucker may transmit the virus from their mouth to their thumb.
  • A health-care worker may develop herpetic whitlow (paronychia)
  • A rugby player or wrestler may get a cluster of blisters on one cheek (‘scrumpox’).

Herpetic whitlow symptoms

The most common locations for herpetic whitlow include:

  • Thumb
  • Index finger
  • Other fingers

Approximately 2–20 days after initial exposure to the herpes simplex virus, the infected area develops burning, tingling, and pain (prodromal phase). Over the next week or 2, the finger becomes red and swollen. Small (1–3 mm) fluid-filled blisters develop, often clustered together on a bright red base. The infection usually involves just one finger but has rarely been noted to involve several fingers. Vesicles usually coalesce into large, honeycomb-like bullae. They may spread proximally and may involve the nail bed where hemorrhagic or purpuric lesions may be noted. Patients will often report a disproportionate intensity of pain, particularly if there is nailbed involvement. Fever, lymphadenitis, epitrochlear and axillary lymphadenopathy may be present. Rarely, lymphedema of the hand and forearm may be present, although reports favor bacterial superinfection in most of these cases.

Vesicular fluid is clear early on but may become turbid, seropurulent, or hemorrhagic as it progresses. There will never be frank pus unless a bacterial superinfection is present. In immunocompromised patients (particularly AIDS with CD4 less than 50), ulceration and necrosis may be seen.The blisters usually rupture and scab over, leading to complete healing after an additional 2 weeks.

Other symptoms occasionally associated with the primary infection of herpetic whitlow include:

  • Fever
  • Red streaks radiating from the finger (lymphangitis)
  • Swollen lymph nodes in the elbow or underarm area

If a person contracts herpetic whitlow from himself or herself (autoinoculation), then he or she is likely to have a primary herpes simplex virus infection of the mouth area or of the genital area.

Repeat (recurrent) herpes simplex virus infections are often milder than the primary infection, though they look alike. A recurrent infection typically lasts 7–10 days. Recurrent herpetic whitlow is rare.

However, people with recurrent herpes simplex virus infections may report that the skin lesions are preceded by sensations of burning, itching, or tingling (prodrome). About 24 hours after the prodrome symptoms begin, the actual lesions appear as one or more small blisters, which eventually open up and become scabbed over.

Triggers of recurrent herpes simplex virus infections include:

  • Fever or illness
  • Sun exposure
  • Hormonal changes, such as those due to menstruation or pregnancy
  • Stress
  • Trauma
  • Surgery

In many cases, no reason for the eruption is evident.

The vesicles tend to be smaller and more closely grouped in recurrent herpes, compared to primary herpes. They usually return to roughly the same site as the primary infection.

  • Recurrent Type 1 HSV can occur on any site, most frequently the face, particularly the lips (herpes simplex labialis).
  • Recurrent Type 2 HSV may also occur on any site, but most often affects the genitals or buttocks.

Itching or burning is followed an hour or two later by an irregular cluster of small, closely grouped, often umbilicated vesicles on a red base. They normally heal in 7–10 days without scarring. The affected person may feel well or suffer from fever, pain and have enlarged local lymph nodes.

Herpetic vesicles are sometimes arranged in a line rather like shingles and are said to have a zosteriform distribution, particularly when affecting the lower chest or lumbar region.

White patches or scars may occur at the site of recurrent HSV attacks and are more evident in those with the skin of color.

Herpetic whitlow diagnosis

Most herpes simplex virus infections are easy for doctors to diagnose. On occasion, however, a swab from the infected skin may be sent to the laboratory for viral culture, which takes a few days to grow or PCR (polymerase chain reaction enzyme-linked immunosorbent assay). A Tzank test consists of scraping the floor of a herpetic vesicle, staining the specimen, and looking for multinucleated “balloon” giant cells, with as high as approximately 70% sensitivity and high specificity for the disease 7). Blood tests may also be performed, but herpes simplex virus serology is not very informative, as it’s positive in most individuals and thus not specific for the lesion with which they present.

Herpetic whitlow treatment

Symptomatic relief and avoidance of secondary infection are the mainstays of therapy for herpetic whitlow. If you develop a tender, painful sore on the finger, see a doctor, especially if it is not going away or if it seems to be getting worse. You should definitely seek medical attention if you have a finger sore as well as typical symptoms of oral or genital herpes.

There is no cure for herpes simplex virus infection.

Untreated herpes simplex virus infections will go away on their own, but medications can reduce the symptoms and shorten the duration of outbreaks. The natural course of the infection in an immunocompetent patient is a spontaneous resolution of symptoms in 2 to 4 weeks 8).

Although herpetic whitlow symptoms will eventually go away on their own, your physician may prescribe antiviral medications in order to help relieve symptoms and to prevent spread of the infection to other people:

  • Acyclovir pills
  • Valacyclovir pills
  • Famciclovir pills
  • Topical acyclovir ointment

These medications are usually taken for 7–14 days.

More severe herpetic whitlow may require oral antibiotic pills if the area(s) are also infected with bacteria.

While there are few studies specific to herpetic whitlow, antivirals have been shown to shorten the duration of symptoms by up to 4 days in one study and decreased days of positive viral culture. Data is especially favorable if the antiviral is started within 48 hours of onset of symptoms. For recurrent herpetic whitlow, suppressive therapy with an antiviral agent may be helpful. Treatment with acyclovir, famciclovir, or valacyclovir has not been specifically compared. Antibiotics must be considered in a secondarily infected digit.

Viral shedding is present until the epidermal lesion is healed, so patients should be counseled on the importance of wearing gloves or another protective barrier. The patient should also be counseled that the chance of recurrence is about 30% to 50%.

Although it is rare, recurrent herpetic whitlow can be treated with the same oral antiviral medications:

  • Acyclovir pills
  • Valacyclovir pills
  • Famciclovir pills
  • Topical acyclovir ointment

People who experience early signs (prodromes) before recurrent infections may benefit from episodic treatment, by starting to take medication after the onset of tingling and burning but before the appearance of blisters and sores.

Very rarely, individuals may have recurrent herpetic whitlow outbreaks that are frequent enough or severe enough to justify suppressive therapy, in which medications are taken every day in order to decrease the frequency and severity of attacks.

Incision and drainage should not be performed as it provides no symptomatic relief and may cause viremia and bacterial superinfection 9). There have been reports of significant pain relief following nail segment excision for decompression of vesicles along the nail bed 10).

Herpetic whitlow natural treatment

Acetaminophen (paracetamol) or ibuprofen may help reduce fever and pain caused by the herpes simplex virus sores. Applying cool compresses or ice packs may also relieve some of the swelling and discomfort.

Because herpes simplex virus infections are very contagious, it is important to take the following steps to prevent spread (transmission) of the virus during the prodrome phase (burning, tingling, or itching) and active phase (presence of blisters or sores) of herpetic whitlow:

  • Avoid sharing towels and other personal care items
  • Cover the affected finger with a bandage
  • Wear gloves if you are a health care provider
  • Don’t pop any blisters—it may make the condition worse

Unfortunately, the herpes simplex virus can still be transmitted even when someone does not have active lesions. However, this is very unusual for patients with herpetic whitlow.

Herpetic whitlow prognosis

Herpetic finger infection is classically self-limited and usually resolve in 2 to 4 weeks for primary infection. After the acute stage, the pain abates, and the vesicles begin to dry and crust. Usually, the pain resolves in about 14 days, and remaining skin changes continue to heal after that. Fingers and nails typically completely heal with no further issues, although there are reports of residual scarring, numbness, and hypersensitivity.

A recurrent outbreak due to latent sensory ganglion infection has been noted in up to 30% to 50% of cases.

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