II. Definition

  1. Herpes Simplex Virus infection of the finger tip

III. Causes

IV. Mechanism

  1. Infection via broken skin

V. Risk Factors

  1. Children with active Herpes Gingivostomatitis
  2. Women with Genital Herpes
  3. Healthcare workers

VI. Symptoms

  1. Initial outbreak
    1. Single digit (typically a finger) with pain, itching and swelling
    2. Fever
  2. Recurrent outbreak
    1. Localized mild burning and itching may precede recurrence by up to 2-3 days

VII. Signs

  1. Vesicles over an erythematous base (appear after symptom onset above)
    1. Contain clear fluid which may become opaque and clouded over time
    2. May coalesce into bullae over 2 weeks
    3. Forms ulcer with hemorrhagic base
  2. Lymphadenopathy
    1. Epitrochlear Lymphadenopathy
    2. Axillary Lymphadenopathy

VIII. Differential Diagnosis

IX. Labs

  1. Not indicated in most cases where the diagnosis is clear (clinical diagnosis is the norm)
  2. Diagnostic testing when indicated
    1. Tzanck Smear
    2. Viral culture
    3. Fluid from lanced Vesicle for HSV PCR

X. Management

  1. Avoid lancing lesions (aside from diagnostic testing)
    1. Lancing increases the risk of Bacterial superinfection
  2. Prevent transmission
    1. Keep lesion bandaged
    2. Keep bandages dry
  3. Antiviral agents
    1. Herpetic Whitlow is self limited and resolves spontaneously without treatment
    2. Indications
      1. Recurrent infection
      2. Immunocompromised status (risk of disseminated HSV)
      3. Consider in first 48 hours to shorten course
    3. Agents
      1. Acyclovir 400 mg PO tid for 7 days
      2. Famciclovir (Famvir)
      3. Valacyclovir (Valtrex)

XI. Course

  1. Resolves spontaneously in 3 to 4 weeks
  2. Recurs in 20 to 50% of cases
    1. Recurrence is usually more mild than initial event

XII. References

  1. Cory in Mandell (2000) Infectious Disease, p. 1569-71
  2. Antosia in Marx (2002) Rosen's Emergency Medicine, 530
  3. Clark (2003) Am Fam Physician 68:2167-76 [PubMed]
  4. Rerucha (2019) Am Fam Physician 99(4):228-36 [PubMed]

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