Pediatric Dermatology

Series Editor: Camila K. Janniger, MD

Herpetic Whitlow
Ines B. Wu, BS; Robert A. Schwartz, MD, MPH

Herpetic whitlow is a painful cutaneous infection secretions or mucous membranes; however, since
that most commonly affects the distal phalanx of the implementation of universal precautions, the
the fingers and occasionally the toes. It is caused incidence has decreased and occupation-related cases
by herpes simplex virus (HSV) types 1 or 2. no longer represent the majority of occurrences.3,4
Herpetic whitlow has been known mainly for infect- Herpetic whitlow mainly occurs in individuals aged
ing healthcare workers in contact with infected 20 to 30 years, with lesions usually autoinoculated
secretions or mucous membranes, but the imple- from HSV-2 genital lesions.3 Children younger than
mentation of universal precautions has resulted in 10 years comprise the next most affected group, with
a decrease in the incidence of occupation-related autoinoculated lesions from HSV-1 gingivostomatitis.3
cases. Herpetic whitlow occurs mainly in adults The peak age of occurrence in the pediatric population
aged 20 to 30 years and children. In children, is within the first 2 years of life.5 In immunocompetent
most cases can be attributed to autoinoculation of individuals, herpetic whitlow is not common; when it
HSV-1, while in adolescents and adults, herpetic does occur, it is a self-limited process.6 As is typical of
whitlow tends to be caused by autoinoculation of HSV-1 and HSV-2, however, herpetic whitlow may
HSV-2. Herpetic whitlow may have a prodrome of recur. Herpetic whitlow recurrences in pediatric cases
burning, pruritus, and/or tingling of the affected occur at a similar rate as adults, with a comparable rate
finger or the entire limb, followed by erythema, for HSV-1 and HSV-2 cases.5
pain, and vesicle formation.
Cutis. 2007;79:193-196. Clinical Manifestations
Herpetic whitlow occurs most commonly on the pulp
of the finger; however, the sides and paronychial

H
erpes simplex virus (HSV) types 1 and 2 are regions of the finger also can be involved. Cases
best known for causing infections in the orola- affecting the toes also have been reported.2,7,8 Primary
bial and genital regions; however, these viruses infection might involve a prodrome of burning, pruri-
also are responsible for a number of other infections, tus, and/or tingling of the affected finger or the entire
including neonatal infection, eczema herpeticum, limb. The prodrome is followed by edema, erythema,
HSV-associated erythema multiforme, and herpetic and pain and tenderness in the affected digit.9-12
whitlow. Herpetic whitlow, first reported in 1909, is Fever, regional lymphadenopathy, and lymphadeni-
a painful cutaneous infection of the fingers or toes tis also can occur.9,10,13,14 Herpetic whitlow initially
caused by HSV-1 or HSV-2.1 The term is derived from is seen as painful deep vesicles filled with clear or
the Scandinavian word whichflaw (which refers to the serosanguineous fluid (Figure).9,10,12 Eventually, the
sensitive area around the nail, flaw means crack).2 vesicles can coalesce,9,10 at which point the infec-
tion mimics a pyogenic bacterial infection and can
Epidemiology be easily misdiagnosed. Vesicles crust after about
Herpetic whitlow perhaps is most known for affect- 10 days. The affected area sometimes undergoes
ing healthcare workers in contact with infected necrosis and sloughs off about one week later.10,12
If a superimposing bacterial infection develops, the
vesicles can become purulent.
Accepted for publication November 8, 2006. Immunocompromised individuals are at risk of
From UMDNJ-New Jersey Medical School, Newark.
developing atypical or severe infections.15,16 They are
The authors report no conflict of interest.
Reprints: Robert A. Schwartz, MD, MPH, Dermatology, UMDNJ- more likely to develop prolonged and invasive infec-
New Jersey Medical School, 185 S Orange Ave, Newark, NJ tions. If left untreated, the infection can lead to rapid
07103-2714 (e-mail: roschwar@cal.berkeley.edu). destruction of the nail.15 One immunocompromised

VOLUME 79, MARCH 2007 193

10. Pediatric herpetic whitlow. can be either symptomatic or asymptomatic. secondary is a recurrence. or DNA amplifi- Though they are serologically distinct.10 In an immunocompetent individual. is primarily attributed to HSV-1. usually at the same site. using the Tzanck test.10 whitlow. and cellulitis. the clinical morphology of extremely painful vesicles plications of herpetic whitlow include superinfec.19 herpetic whitlow infection in that area. tion with Staphylococcus aureus and other bacteria.5 Though the cor- recurrent infections.4 One child developed herpetic whitlow 3 days girl. it is ideal to avoid unnecessary antibiotic spread.21 rect diagnosis eventually was reached with further In order for HSV-1 and HSV-2 infections to tests. Herpetic whitlow replicates again and produces recurrent infection that often is misdiagnosed because it mimics paronychia.21 when a mother sucks her infant’s toe. viral culture. it should always it reaches the dorsal root ganglion that innervates be considered in the differential diagnosis of an the primary site of viral replication.4 ily.5 ation. HSV-1 infection usually is acquired before the age of 5 years. the virus finds its way from an active lesion Viral culture and DNA amplification techniques are or infected secretions to an area of broken skin. child sucks his/her thumb or bites his/her finger- nails. HSV-2.6 several cases of unknown etiology. Hence.10. which can be achieved Herpetic whitlow is caused by HSV-1 and HSV-2.21 For primary herpetic whitlow in a child. ing the vesicle and scraping the base of the lesion. bacterial felon.17 Herpetic whitlow also can be the first sign or when an infant explores the mouth of an infected of an immunocompromised state. needle puncture.5 Infection with Painful coalesced vesicles with surrounding erythema HSV-1 in the orolabial region can occur when the on the finger.Pediatric Dermatology skin area with active lesions or infected secretions.22 There have been human immunodeficiency virus infection. and up to 40% of children demonstrate antibodies for HSV-1. primary infections tend to be more severe than whitlow as a bacterial infection. herpetic whitlow was the first manifestation of after swinging on monkey bars.18. child’s fingers.9 The Tzanck test is done by unroof- and HSV-2 are part of the Alphaherpesvirinae fam. with lesions resolving Diagnosis within 14 to 21 days. and Varicellovirus.10. many cases of herpetic whitlow occur as a sequela of primary or recurrent HSV-1 or HSV-2 infection in the orolabial or genital areas. They share genetic similarities and produce A positive Tzanck test shows multinucleated giant similar primary and recurrent infections. The virus also travels along the nerves until is not commonly seen in children.5 There also either the patient or close contacts.4. or cervix secretions of an asymptomatic individual. on the fingers or toes. there often is a history of recent HSV infection in nail dystrophy. Recur.4. often from the saliva. herpetic whitlow because of misdiagnosing herpetic als.2. the infec- tion usually is self-limited.10 Recognized com. 194 CUTIS® .15 Antibiotics rent infections tend to occur in the same site as the have been started in 65% of documented cases of primary infection. Confirma- tion of the diagnosis requires definitive proof of HSV Pathophysiology infection in the affected area. and permanent nail loss.20 In herpetic cells specific for HSV-1.5. both HSV-1 cation techniques. and systemic viremia.13 Another mechanism of spread is exogenous adult developed gangrenous herpetic whitlow with sources. when the virus lead to the wrong treatment.8. It lies latent infection of the finger because misdiagnosis can there until the reactivation stage. espe- cially in children younger than 2 years.9 Recurrence occurs in 20% of The diagnosis of herpetic whitlow usually is based on cases.23 and produces symptomatic infection in the form of Differential Diagnosis—Although herpetic whitlow vesicles. such as when an infected individual kisses a partial destruction of the nails and deep skin ulcer. there must be direct contact of an open therapy or surgery. The pri- mary mechanism is autoinoculation. such conducted using fluid obtained from the vesicle via as an abrasion or a torn cuticle on the finger or toe.5 Serologic studies are not helpful After infecting epithelial cells. semen. there are several proposed mechanisms of spread. the virus replicates in diagnosing herpetic whitlow. there will be a history of previous ocular involvement. In a 10-year-old adult. If the infection have been reports of local hypoesthesia.11 In immunocompetent individu.5 If the infection is primary.

2005.3 to 0. or famciclovir. can become cloudy secondary to bacterial superin.30:609-610. compromised individuals with any form of herpes 16.68:2167-2176. et al. and treatment of bacterial super.   1. Abramo TJ. symptomatic pain relief Dermatol Online J.22:119-121. Saha M. Am Fam shedding occurs until the lesion heals.93:828-830.22:111-116. Am J Dis rial infection. Zuretti AR. sible that these vaccines also might be effective First. Dermatol. Herpes febrilis attacking the fingers. 1909.2 Finally.   8. Szinnai G. Bernardi S.8.13:213-215. Am J Clin limited studies proving the efficacy of this course Dermatol. One double-blinded.10(1):16.24 Treatment   7. J Infect Dis.131:743-744. with analgesics. placebo-controlled.3:475-487. Egan LJ. Indolent herpetic whitlow includes halting viral replication with acyclovir. whether it is localized or disseminated.137:855-856. Although it would seem logical to prescribe anti. Crane LR. Herpes simplex mimick- infection.10 petic whitlow lesions in a 4-year-old girl: case report and review of the literature. Pierard GE.   4. in which the defined risks. et al. Br J lation is a common mechanism of spread. Herpetic usually is self-limited. 2002. It ing leukemia cutis.6 days. lesions are filled with cloudy fluid from the start due   5. clinical characteristics. a profile of 79 cases.26 Topical acyclovir does not provide a 15. herpetic whitlow helped reduce symptom duration 13. 1995. Herpetic whitlow in immunocompetent individuals   6. Jordan MB. Heininger U. Common acute hand infections. Occurrence of herpetic crossover study showed that oral acyclovir adminis. worsen symptoms and even lead to viremia or bacte.   3. 2001.5 herpetic whitlow in AIDS: report of three cases. Feder HM Jr. Herpetic the individual or any close contact suggests herpetic whitlow of the toe: an unusual manifestation of infec- whitlow. Tagami H. Clin Infect Dis.137:861-863. et al. herpes whitlow characteris. Agerter DC. from 5. Bunker CB. Herpetic whitlow. Robayna MG. particularly HSV-2. epidemiology. Herpes simplex virus tically has nonpurulent vesicular fluid. Herpetic whitlow: a whitlow. J Am Acad Dermatol. diagnosis. Rubio FA. Clin Pathol. Buchan K. Buchan KA. Feder HM Jr. Mohler A. 2005. tered during the prodromal stage of recurrent HSV-2 1994. Ozawa M. Lesher JL Jr.15 a human immunodeficiency virus–positive patient. Herpetic whitlow in an infant without fection. therefore. HSV infection. Gill MJ. 12. Clin Exp Dermatol. Research is being conducted of primary infection with herpes simplex virus type 1 or to develop vaccines for the prevention and/or type 2.9. a history of trauma to the nail cuticle or skin against herpetic whitlow. Recurrence of similar symptoms at the same tion with herpes simplex virus type 2.12 Symptoms last a few weeks.7 days and positive viral cultures tion of the hand. Arlette J. Multiple her- to the presence of pus.24 In addition. Adamson H. Pediatr Infect Dis J. after Pediatr Dermatol. Herpetic whitlow of the toe. Br J Systemic acyclovir is indicated in immuno. Herpetic whitlow: a manifestation dangerous infection. 1990. Destructive clear benefit in the treatment of herpetic whitlow. 1990. Treatment of mucocutaneous viral medication to treat herpetic whitlow. recurrence can decrease with daily use of forgotten diagnosis. of action.137:812-815.25 In treating recurrent herpetic 14. Gangrenous herpetic whitlow in infections in immunocompromised individuals. Herranz P. nocompromised individuals from such a potentially 18. Schaad UB. Eur J Pediatr. Hassel MH. Lerner AM. symptomatic.21: is the therapy of choice not only for the treatment 367-371. Bylander JM. 11. MARCH 2007 195 . Giraldi L. Bowling JC. nail biting) might indicate herpetic whitlow because the trauma provides a mode of References entry for the virus.10.10 Child. site also should alert the diagnostician to possible 1998.26:196-197. VOLUME 79. the lesion covered with a dry dressing because viral   9. Nikkels AF. Arch Dermatol. Pediatric Dermatology There are a few characteristics that can help treatment of HSVs.84:89-93. J Am Acad Dermatol. Am J Perhaps a vaccine is the best way to protect immu. Gill MJ.21:323-324. Schwartz IS. treatment often is whitlow as a harbinger of pediatric HIV-1 infection. Arlette J. 2000. valacyclovir.10 The fluid in infection of the hand. the vesicle initially is clear or serosanguineous and 1988.1 to 3. there are presentations of herpes simplex virus infections. and drainage should be avoided because it can 10.24 It is important to keep Pract. oral acyclovir. of HSV infections but also to prevent recurrent 17. El Hachem M.160: Comment 528-533. Am J Med. which healing usually is complete. 1997.13:832-833. Ohtani T. unlike bacterial paronychia. a recent Dermatol. whitlow in a twelve-day-old infant. of the toe in an elderly patient with diabetic neuropathy. history of orolabial or genital herpetic lesions in   2. 2004. 1978.5.27 of the finger (eg. because autoinocu. and treatment. It is pos- distinguish herpetic whitlow from other conditions. J Am Board Fam infection with antibiotics.10 Incision Physician. 2003. Long SS. 1989. Clark DC. Herpes simplex virus infec- from 10. 1983.

Schleiss MR. Bhumbra NA. 20. Curr Top Microbiol Immunol. Acyclovir and suppression of frequently recurring herpetic whitlow. Herpetic whitlow and keratitis. Recurrent herpetic whitlow in an immune competent girl without vesicular lesions. Ann Intern Med. Wilson R. 2003. Skin and subcutaneous infections. 22. Pediatr Infect Dis J. Villines TC. 23. Vaccines for viral diseases with dermatologic manifestations. Bryant HE. Kopriva F.102: 494-495. 27. Stover B. 2005. 1985. 2003.179:15-30. Pathogenesis of herpes simplex virus infec- tion and animal models for its study. Fong W. Laskin OL. Stanberry LR. Eiferman RA. Adams G. Primary palmar herpes simplex virus 1 infection in a ten-year-old girl. Prim Care. 2002. Lee PC.11:338-339. 21. Antimicrob Agents Chemother. 26. Am Fam Physician. Brentjens MH.161:120-121. 196 CUTIS® . 1992. Oral acyclovir therapy of recur- rent herpes simplex virus type 2 infection of the hand. 24. Eur J Pediatr. 1991. 1979. et al.35:382-383.97:1079-1081. Dermatol Clin.21:349-369. Gill MJ. McCullough SG.72:317-318.30:1-24. et al. Truesdell AG. Arch Ophthalmol.Pediatric Dermatology 19. Inflammatory lesions on every finger. Yeung-Yue KA. 1992. 25.