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herpetic whitlow
Herpes simplex infection of the fingers
Etiology:
- Herpes simplex
a) HSV1 (60%)
b) HSV2 (40%)
Epidemiology:
- in children, autoinoculation from primary oropharyngeal lesions, most commonly HSV1
- in adults, autoinoculation from genital herpes, most commonly HSV2
- common among dentists, dental hygienists & pulmonary nurses prior to adherence to universal precautions
- males, females equally susceptible
- viral shedding resolves with symptoms
Pathology:
- after primary infection, HSV enters cutaneous nerve endings & migrates to dorsal root ganglia & Schwann cells where it lies dormant
- recurrences occur in 20-50% of cases & are usually milder of shorter in duration than the primary infection
Clinical manifestations:
- incubation period of 2-20 days
- prodrome of fever & malaise less common than presentation with paresthesias & pain of affected fingers
- involves 1 or more fingers of the hand
- generally affects terminal phalanx
- intensely painful
- erythema, edema, vesicular lesions (1-3 mm) grouped on an erythematous base appear over 7-1o days following initial presentation
- lymphadenopathy (epitrochlear & axillary)
- after 10-14 days, symptoms generally improve & lesions crust & heal
- complete resolution within 21 days of presentation
- recurrences not uncommon [2]
* images [3,4]
Laboratory:
- Tzanck test
- viral culture of aspirated vesicle fluid
- HIV testing if atypical presentation, recurrent infection
Differential diagnosis:
- cellulitis
- paronychia
- felon
Complications:
- iatrogenic complication
- bacterial superinfection
- herpes encephalitis (rare)
Management:
- self-limited disease
- topical acyclovir 5% shortens duration of symptoms & viral shedding
- oral acyclovir for 7 days [2]
- acyclovir 800 mg PO BID during prodrome may abort recurrence
- unroofing vesicles & wedge resection of fingernail may ameliorate symptoms &/or lead to iatrogenic complications
- intravenous acyclovir with switch to oral valacyclovir as symptoms begin to resolve [4]
General
viral infection
occupational disease
References
- Omori MS
Herpetic Whitlow
eMedicine
http://emedicine.medscape.com/article/788056-overview
- Izzo S, Ahmed M
Herpetic Whitlow
N Engl J Med 2014; 371:e25. October 23, 2014
PMID: 25337767
http://www.nejm.org/doi/full/10.1056/NEJMicm1311820
- Brady MP (images)
Cutaneous and Mucosal Manifestations of Viral Diseases.
Medscape. March 2017
http://reference.medscape.com/features/slideshow/viral-skin
- Shoji K, Saitoh A
Herpetic Whitlow
N Engl J Med 2018;378:563-563. February 8, 2018
http://www.nejm.org/doi/full/10.1056/NEJMicm1711479