Herpetic Whitlow

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

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
Lymphadenopathy
1. Epitrochlear Lymphadenopathy
2. Axillary Lymphadenopathy

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

Avoid lancing lesions (aside from diagnostic testing)
1. Lancing increases the risk of Bacterial superinfection
Prevent transmission
1. Keep lesion bandaged
2. Keep bandages dry
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)

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