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Updated: 5/16/2021

Herpetic Whitlow

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  • Summary
    • Herpetic Whitlow is a viral infection of the hand caused by herpes simplex virus (HSV-1).
    • Diagnosis is made clinically by presence of a small, vesicular rash and confirmed with a Tzank smear.
    • Treatment is observation with a short course of antiviral antibiotics (acyclovir).
  • Epidemiology
    • Incidence
      • rare
        • 2.4 cases per 100,000 people per year
    • Demographics
      • occurs with increased frequency in medical and dental personnel
      • most common infection occurring in a toddler’s and preschooler’s hand
  • Etiology
    • Pathophysiology
      • viral shedding occurs while vesicles are forming bullae
  • Presentation
    • Symptoms
      • intense burning pain followed by erythema
      • malaise
    • Physical exam
      • erythema followed by small, vesicular rash
        • over the course of 2 weeks, the vesicles may come together to form bullae
        • the bullae will crust over and ultimately lead to superficial ulceration
      • fever and lymphadenitis may be found
  • Studies
    • Tzank smear
      • diagnosis confirmed by culture, antibody titers or Tzank smear
  • Diagnosis
    • Clinical and culture-based
      • diagnosis is made with careful history and physical examination and confirmed with a positive Tzank smear
  • Treatment
    • Nonoperative
      • observation +/- acyclovir
        • indications
          • standard of treatment
        • outcomes
          • self limiting, with resolution of symptoms in 7-10 days
          • acyclovir may shorten the duration of symptoms
          • recurrence may precipitated by fever, stress and sun exposure
    • Operative
      • surgical debridement
        • indications
          • none
            • surgical treatment associated with superinfections, encephalitis, and death and should be avoided
  • Complications
    • Superinfections
      • often the result of surgical intervention
        • in pediatric patients, an infection of the digits may occur and require treatment with an oral antibiotic (penicillinase resistant) ifor 10 days
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