Herpetic whitlow

A14-month-old child presented to our dermatology clinic with a 2-week history of painful swelling of the right forefinger and a painful mouth ulcer (Figure 1). She had been seen three times at the local emergency department and was receiving oral antibiotics for a presumed bacterial infection, and antiseptic mouthwashes. The finger showed localized swelling, redness and tenderness with grouped pustules. There were also swollen and painful lymph nodes in the patient’s right armpit, consistent with lymphangitis. Swabs and fungal cultures taken from the affected areas showed no growth. However, virologic findings supported a diagnosis of a herpetic whitlow and gingivostomatitis aphthosa caused by herpes simplex virus (HSV) type 1. We prescribed oral acyclovir for 1 week and topical antiseptics.1 The patient’s lesions resolved within 10 days.

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Figure 1:

(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.

Herpetic whitlow is a lesion on a finger or thumb caused by either HSV type 1 or 2 during primary infection. The condition is usually seen in children and young adults. In children, it tends to co-occur with gingivostomatitis aphthosa. Oral secretions are a source of infection, so, among adults, health care workers and athletes engaging in contact sports (e.g., rugby players or wrestlers) are at risk for viral exposure.2 The clinical picture typically consists of grouped vesicles or ulcers on an erythematous base, but additional analyses (e.g., polymerase chain reaction enzyme-linked immunosorbent assay) may be required for a definite diagnosis.

Herpetic whitlow should be distinguished from other infectious diseases (e.g., bacterial whitlow) because of the different treatments required.3 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