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Whitlow

Finger Pulp Abscess

Purulent inflammation of a tip of a finger or a toe due to infection by the herpes simplex virus (HSV) is called whitlow, herpetic whitlow, or whitlow finger. It can occur when there is contact between a broken skin layer and body fluids infected with HSV and often affects the fleshy portions of the fingertips. A form of melanoma closely resembles whitlow and is called melanotic whitlow.


Presentation

Whitlow presents as pain and swelling of a finger following several days of viral incubation. There may also be associated burning, tingling, or itching sensation of the finger and the presence of vesicular lesions in the affected area. These vesicles usually contain serous fluid and may become purulent only if bacterial superinfection occurs.

The appearance of a painful swollen finger may be preceded for several days by a prodrome of fever, fatigue, or malaise. This represents the incubation period of HSV when the virus is still multiplying and is yet unable to produce a full-blown infection.

The pain and swelling may abate spontaneously after 10 -14 days, and the vesicles start to form crusts and eventually heal.

Malaise, fever, lymphadenitis, or lymphangitis may be associated with herpetic whitlow in certain rare cases [16] [17].

Axillary Lymphadenopathy
  • Physical examination revealed an area of erythematous, confluent vesicles on the middle phalanx of the finger and associated axillary lymphadenopathy.[nejm.org]
  • Lymphangitis and epitrochlear and axillary lymphadenopathy are not uncommon. After 10-14 days, symptoms usually improve significantly and lesions crust over and heal. Viral shedding is believed to resolve at this point.[emedicine.medscape.com]
Malaise
  • A previously healthy 18-year-old woman presented with a 2-week history of fever, malaise, and a painful left middle finger.[nejm.org]
  • The appearance of a painful swollen finger may be preceded for several days by a prodrome of fever, fatigue, or malaise.[symptoma.com]
  • […] frequency in medical and dental personne l most common infection occurring in a toddler’s and preschooler’s hand Pathophysiology viral shedding occurs while vesicles are forming bullae Presentation Symptoms intense burning pain followed by erythema malaise[orthobullets.com]
  • Although a prodrome of fever and malaise may be observed, most often initial symptoms are pain and burning or tingling of the infected digit.[emedicine.medscape.com]
Swelling of the Finger
  • There is dull pain, redness and swelling of the finger, throbbing and severe tenderness. At this stage, the condition may often be controlled with antibiotics.[medical-dictionary.thefreedictionary.com]
  • When bone panaritiums kolboobraznoe marked swelling of the finger nail bone, tenderness to palpation, sometimes defined bony crepitus. Radiographically for bone panaritiums found sequestered bone. Treatment of bone panaritium operative.[minclinic.ru]
  • Whitlow presents as pain and swelling of a finger following several days of viral incubation. There may also be associated burning, tingling, or itching sensation of the finger and the presence of vesicular lesions in the affected area.[symptoma.com]
  • […] below the finger nails A painful couple of blisters that are filled with fluid A redness around the finger(it can be quite severe in some cases) Burning sensation on fingers Itchy feeling Swollen and extremely painful Uncontrollable or even extreme Tingling[nigeriagalleria.com]
Hyperpigmentation
  • A form of skin cancer called melanotic whitlow has a similar appearance as whitlow except that the affected area of the finger exhibits a darker color (hyperpigmentation). The treatment for this condition is different from herpetic whitlow.[symptoma.com]

Workup

The most specific diagnostic test for herpetic whitlow is viral culture of the vesicle fluid. Tzanck test may be performed by scraping the vesicles and spreading the samples on a glass slide, where they are stained with Giemsa and examined under a microscope. However, the Tzanck test carries a low sensitivity. Other definitive tests include DNA hybridization, polymerase chain reaction, or immunofluorescent microscopy.

HIV testing is recommended for patients with recurrent infections and atypical presentations of whitlow [10] [11].

Treatment

Whitlow does not require any treatment and will resolve spontaneously since it is a self-limited disease. Treatment with antiviral drugs such as topical acyclovir or penciclovir may be applied in order to decrease the duration of the disease, reduce the risk of spreading the virus to other areas of the body, lower the risk of bacterial infection, or decrease viral shedding. Oral acyclovir may also be used to prevent recurrence, and famciclovir or valacyclovir may reduce the duration of clinical recurrence.

Surgical techniques to unroof a vesicle or wedge resection of a nail in subungual infections may be performed in order to provide symptom relief. However, deep surgical incision should not be performed, as this can cause bacterial superinfection or viral encephalitis if the virus spreads through the systemic circulation.

Since melanotic whitlow is a malignant lesion and not an infection, its treatment is similar to those of other forms of skin malignancies. Wide local excision with at least 1-2 cm margins is recommended, whereas extensive or deep lesions should be managed by amputation of the affected digit.

Prognosis

Herpetic whitlow may resolve spontaneously even when left untreated. However, the use of antiviral creams may lessen the symptoms and shorten the course of the disease. This condition does not usually cause complications unless secondary bacterial infection occurs, causing a longer course and additional treatment. In some cases, viral encephalitis may also develop [7] [12].

It is believed that melanotic whitlow carries a similar degree of malignancy compared to other types of melanoma [13]. However, some evidence suggests that it may have a relatively better prognosis [14] [15]. Treatment is ineffective and of no clinical use in cases of metastasis.

Etiology

Herpetic whitlow is caused by direct transfer of HSV-1 or HSV-2 from herpetic lesions to a finger with a broken skin barrier. This can happen when a person touches a cold sore or genital herpes lesions, allowing the herpes virus to invade the damaged skin layer. The source of the virus may be from the same person (autoinoculation) or another person infected with HSV. Whitlow commonly develops in patients with weakened immune systems since this is a condition that allows latent HSV in the neurons to reactivate.

Epidemiology

The estimated incidence of whitlow in the United States is approximately 2.4 to 5 cases per 100,000 population, with no predilection for gender. Toddlers and preschool children are more commonly affected since their age group has a tendency to practice thumb-sucking. In terms of HSV serotypes, HSV-1 infection is more prevalent in medical personnel whereas HSV-2 has a greater tendency to infect the general population [4]. Herpetic whitlow may either be an initial or recurrent infection due to the capacity of HSV to remain latent in the neurons of the peripheral ganglia [5] [6] [7]. However, the rate of recurrence is variable [7] [8], with some patients experiencing more recurrence than others.

Melanotic whitlow accounts for approximately 2.9 to 15% of all melanomas [9] [10], and evidence suggests that around 9% of melanotic whitlow originates in the subungual space [11].

Sex distribution
Age distribution

Pathophysiology

Herpetic whitlow occurs when HSV is inoculated onto a damaged skin barrier through infected bodily fluids. After inoculation, the virus penetrates the deeper skin layers and the subcutaneous tissue, causing clinically significant infection after an incubation ranging from 2-20 days.

Several age groups and patient populations may be affected by the two HSV serotypes. Younger age groups tend to be infected with HSV-1 transmitted by autoinoculation (through thumb-sucking) from herpetic lesions in the mouth such as herpetic gingivostomatitis or herpes labialis. Whitlow in adults are also commonly caused by autoinoculation. However, the virus most often involved in the transmission of the disease is HSV-2 from genital herpes. Healthcare workers are most often infected by HSV-1 resulting from unprotected contact with infected oropharyngeal or genital secretions from patients.

The primary infection with HSV usually produces a highly symptomatic disease. Once HSV penetrates the skin, it can migrate to the Schwann cells and peripheral ganglia and lies dormant until certain conditions allow it to be reactivated. Recurrence of herpetic whitlow is generally milder, less symptomatic, and has a shorter duration than the initial infection in around 20-50% of patients.

Prevention

Proper handwashing [2] and the use of gloves among medical personnel may decrease the risk of herpetic whitlow. Healthcare workers with active disease should avoid direct contact with patients, especially the immunosuppressed, neonates, pregnant women, transplant patients, or patients with severe burns [18] [19]. Patients with recurrent whitlow should undergo evaluation to detect conditions that affect the immune function.

Summary

Whitlow, whitlow finger, or herpetic whitlow is an infection affecting the fingers, usually on the terminal phalanx [1], caused by herpes simplex virus (HSV). It is characterized by painful, itchy, erythematous inflammation of the fingers and may be accompanied by blisters at the site of infection. A serious infection should be suspected in the presence of fever, red streaks on the hands or the arms, and significant lymphadenopathy.

Since the transmission of this condition relies on contact of HSV-infected body fluids with broken skin, herpetic whitlow is considered as an occupational hazard among healthcare workers [2]. It can be caused by both serotypes of HSV, with HSV-1 accounting for 60% of cases and HSV-2 in the remaining 40%.

Although antiviral medications may be given to reduce the symptoms and duration of whitlow, it usually resolves spontaneously after 2 to 3 weeks even without medication. However, HSV may remain dormant or latent in the neurons and may become active in immunodeficient states such as extreme stress or the presence of a previous or existing infection. The same treatment may be given if the whitlow reappears.

A form of melanoma called melanotic whitlow may sometimes be mistaken for herpetic whitlow and is responsible for many misdiagnosed and mistreated cases [3]. Melanotic whitlow differs from herpetic whitlow in the sense that the affected area is hyperpigmented and has a malignant course.

Patient Information

Herpetic whitlow is a disease caused by the herpes virus. It usually affects the fingertips and causes pain, redness, or swelling of the affected fingers, as well as itching or tingling sensations. Blisters with clear fluid may also form.

This disease is transmitted through contact of broken skin with fluids containing herpes virus. Children with cold sores may get this disease if they are fond of thumb-sucking. Persons with genital herpes and healthcare workers may also develop this disease.

A light dressing should be applied on the affected area to prevent spread of the infection. Avoid wearing contact lenses or rubbing your eyes as they may be infected with the herpes virus. Analgesics such as paracetamol or ibuprofen may be taken for pain relief. It is important to note that herpetic whitlow is a self-limited disease, which means that it will resolve spontaneously after 2 or 3 weeks even without medication.

A form of skin cancer called melanotic whitlow has a similar appearance as whitlow except that the affected area of the finger exhibits a darker color (hyperpigmentation). The treatment for this condition is different from herpetic whitlow. Since this is a form of skin cancer, excision of the whole lesion is the most effective treatment. The outcome depends on early detection and correct diagnosis of this condition.

References

Article

  1. Wu IB, Schwartz RA. Herpetic whitlow. Cutis. 2007; 79(3):193-6.
  2. Klotz RW. Herpetic whitlow: an occupational hazard. AANA J. 1990; 58(1):8-13
  3. Gibson SH, Montgomery H, Woolner LB, Brunsting LA. Melanotic whitlow (subungual melanoma). Journal of Investigative Dermatology.1957; 29, 119-129; doi:10.1038/jid.1957.79
  4. Novick NL. Autoinoculation herpes of the hand in a child with recurrent herpes labialis. The American Journal of Medicine. 1985; 79 (1):139-142
  5. Merchant VA, Molinari JA, Sabes WR. Herpetic whitlow: Report of a case with multiple recurrences. Oral Surgery Oral Medicine Oral Pathology. 1983; 55(6):568-571.
  6. Laskin OL. Acyclovir and suppression of frequently recur- ring herpetic whitlow. Annals of Internal Medicine. 1985 ;102(4):494-495.
  7. Palenik CJ, Miller CH. Occupational herpetic whitlow. Journal of the Indiana Dental Association. 1982; 61(6):25-27.
  8. Manzella JP, McConville JH, Valenti W et al. An outbreak of herpes simplex virus type I gingivostomatitis in a dental hygiene practice. JAMA. 1984; 252: 2019-2022.
  9. Gavelin GE, Knight CR. Herpes simplex infection of the finger. Canadian Medical Association Journal. 1965; 93:366-367.
  10. West KH. Herpetic whitlow- A new concern for health care professionals. Journal of Operating Room Resident Instruction. 1983; 3(4):6-8.
  11. Berkowitz RL, Hentz VR. Herpetic whitlow-A non-surgical infection of the hand. Plastic and Reconstructive Surgery. 1977; 60(1):125-127.
  12. Byth PL. Herpetic whitlow. Intensive Care Medicine. 1984; 10(6):321-322.
  13. Wright CJE. Prognosis in cutaneous and ocular malignant melanoma: A study of 222 cases. J Path & Bact. 1949; 61: 507–525.
  14. Newell C E. Malignant melanomas with particular reference to the subungual type. South M J. 1938; 31: 541-547.
  15. Farrell H J. Cutaneous melanomas with special reference to prognosis. Arch. Dermat. & Syph. 1932; 26: 110-124.
  16. Robayna MG, Herranz P, Rubio FA, et al. Destructive herpetic whitlow in AIDS: report of three cases. Br J Dermatol. Nov 1997. 137(5):812-5.
  17. El Hachem M, Bernardi S, Giraldi L, Diociaiuti A, Palma P, Castelli-Gattinara G. Herpetic whitlow as a harbinger of pediatric HIV-1 infection. Pediatr Dermatol. 2005; 22(2):119-21.
  18. Jarris RF, Kirkwood CR. Herpetic whitlow in family practice. The Journal of Family Practice. 1984; 19(6):797-801.
  19. Louis DS, Silva J, Jr. Herpetic whitlow: Herpetic infections of the digits. The Journal of Hand Surgery. 1979; 4(1):90-93

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Last updated: 2017-08-09 18:17