Herpetic Whitlow of the Toe

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J Am Board Fam Pract: first published as 10.3122/15572625-13-3-213 on 1 May 2000. Downloaded from Herpetic Whitlow of the Toe

Andrew Mohler, MD

Herpes simplex virus (HSV) is a common pathogen bridement of the pad and sulcus. There were that can infect any cutaneous or mucocutaneous several small vesicles surrounding the toe in addi site. Although the most common types of primary tion to the papules previously noted (Figure 1). No infections are gingivostomatitis and genital her lymphadenopathy was observed. The patient's pes, l infection of the finger is also frequently re mother reported a history of cold sores in multiple ported. In 1909 Adamson published the first report family members, including the patient's mother, of herpetic infections of the hand.2 The term her father, and 2-year-old and 4-year-old siblings. She petic whitlow was first applied by Stern in his 1959 also noted the patient's habit of putting her own description of 54 neurosurgical unit nurses with toes in her mouth. infections of the finger. 2 \Vhitlow comes from the The base of an unroofed vesicle of the toe was Scandinavian whichflaw, which means a crack in the swabbed for herpes simplex virus (HSV) culture. sensitive area around the nail. 3 Some authors have The patient was given intravenous acyclovir, as well expanded the definition of whitlow to describe all as intravenous ampicillin-sulbactam for possible digital herpetic infections, including the uncom bacterial superinfection. Viral culture was positive monly reported herpetic infection of the toe. The for HSV-l. After 4 days of intravenous acyclovir, following case report describes a case of herpetic the toe had improved, and the patient's medications whitlow of the toe with a previously unreported were changed to oral acyclovir. Acyclovir was dis mode of infection. continued after 5 additional days of continued im provement. Case Report A previously healthy 13-month-old girl was admit Discussion ted to Phoenix Children's Hospital with inflamma There are few cases of herpetic whitlow of the toe tion of her left fifth toe. Approximately 10 days in the literature. One report describes a 3-year-old earlier her mother had noted a blister on the lateral girl with HSV-l infection of the great toe thought

aspect of that digit. Oral antibiotics were pre to have been infected when her mother with herpes http://www.jabfm.org/ scribed for presumed bacterial cellulitis. The pro labialis trimmed her daughter'S toenails using her cess worsened, however, with increased swelling teeth." In another case, a 28-year-old woman with and erythema of the toe. The mother brought the genital herpes developed HSV-2 infection of her girl to her family physician, who noted an area of toe. S The authors of the report propose neural necrosis of the pad and sulcus of the toe surrounded transmission from the sacral ganglia to the toe or autoinoculation through toe-genital contact as pos

by erythema and several small red papules scattered on 28 September 2021 by guest. Protected copyright. over the dorsal and plantar surfaces of the foot. The sible modes of transmission. In the current case patient underwent debridement of the necrotic area report, the most likely mode of transmission is and was admitted to the hospital. At admission the autoinoculation through oral-pedal contact. No child was febrile (rectal 101.5°F) and agitated but previous cases proposing this form of transmission consolable. An examination of her mouth showed were found by a literature review. several 2- to 3-mm white ulcers of the buccal mu Because herpetic whitlow of the toe is so rarely cosa and gingiva. The left fifth toe was erythema reported, there is little information available about tous and edematous, with evidence of surgical de- the epidemiology, clinical characteristics, natural history, or treaonent of this disease. Fortunately, infection of the finger has been very well described. Submitted, revised, 9 June 1999. The anatomic and physiologic similarities of the From the Good Samaritan Family Practice Residency finger and toe would suggest that most of the in Program, Phoenix, Ariz. Address reprint requests to Andrew Mohler, MD, Good Samaritan Family Practice Residency formation known about finger infections would be Program, 1300 North 12th Street #605, Phoenix, AZ 85006. applicable to infections of the toe. A brief review of

Herpetic \Vhitlow of the Toe 213 J Am Board Fam Pract: first published as 10.3122/15572625-13-3-213 on 1 May 2000. Downloaded from limited, typically resolving within 10 to 14 days. Recurrences are common, occurring in about 30% to 50% of ca es. In general, the initial infection is the mo t evere.7, ,10 Because of its similarities to bacterial cellulitis or a paronychia, herpetic whitlow of the finger is often mistaken for a bacterial infection and treated inef fectively with antibiotics or even surgery. Similarly, in case reports of herpetic whitlow of the toe, in cluding this one, the patients were initially thought to have bacterial cellulitis.4,5 In making this diagnosis, it is important to note the hi tologic difference between the skin of the finger and the toe. In their description of 79 case of herpetic infection of tlle hand, ill et a16 found that in areas of highly keratinized skin, lesions sel dom ulcerated. Based on this study, one might expect the appearance of lesions of the more highly keratinized toe to differ slightly from the well Figure 1. Herpetic whitlow of the toe caused by herpes described appearance of finger lesions. simplex virus type 1 in a 13-month-old girl. There have been no formal tudies to as ess th.e efficacy of antiviral medications for uppre sion of recurrent herpetic whitlow. limited number of herpetic whitlow of the finger, therefore, might be case reports of finger infections, however, sugge t beneficial for properly diagnosing and treating that acyclovir might be beneficial. One report whitlow of the toe. howed a decrea ed recurrence rate in a patient 1 The age distribution of herpetic infection of the taking daily oral acyclovir. I Another case report finger is bimodal. The fir t peak, which occur in howed that twice-daily oral acyclovir for 5 days young children, is primarily caused by autoinocu initiated at the onset of the prodromal pha e mark lation from oral ecretions containing HSV-l. The edly decrea ed the likelihood of lesion appear ance. 12 Although the literature regarding suppres econd peak, occurring from 20 to 40 years of age, http://www.jabfm.org/ sive therapy for herpetic whitlow is limited, the is also typical1y caused by autoinoculation; how prevention of recurrent genital herpes infection ever, the usual pathogen is HS -2 from genital has been much more widely studied. Daily dosing contact. Health care worker are at exceptional risk of acyclovir in patients who have more than six for contracting herpetic whitlow from the infected episode of genital Ie ion per year reduces the ecretion of patients, accounting for about 9% of recurrence rate by approximately 75%.13 When

all case .6 on 28 September 2021 by guest. Protected copyright. treatment is in tituted during the prodromal period Herpetic infection of the finger often begins or within the first 2 days of the development of with a period of inten e pain, pruritu , or both that genital Ie ion, the severity of the infection is no can involve the entire arm or only the infected ticeably reduced. Whether suppressive therapy i a digit. The patient can al 0 have ystemic symp effective for herpetic whitlow remains to be shown toms, uch a malai e and fever.~ Following this in a large- cale study. prodrome, the di tal finger become erythematou Cases of apparently succe sful treatment of ex and edematou . Painful, deep vesicle typically ap i ting whitlow Ie ions with acyclovir have also been pear on the di tal egment of the digit. he ve icle reponed. H in the case of uppres ive therapy for can coale ce and result in damage to a large area of recurrent whitlow, however, large-scale studie on tissue.8 The lesions, which might appear to contain the treatment of existing lesions have not been pus, ahno t alway contain clear or ero anguineous published. ne author recommends u ing intrave fluid. Q Lymphangiti and axillary or epitrochlear nous acyclovir for initial episodes of whitlow of the lymphadenopathy can be pre ent. Lesion are elf- finger, for infection in immunocompromi ed pa-

214 JABFP ~1ay-June 2000 Vol. 13 TO . 3 J Am Board Fam Pract: first published as 10.3122/15572625-13-3-213 on 1 May 2000. Downloaded from tients, and for severe infections associated with References constitutional symptoms.! Until further studies are 1. Arbesfeld DM, Thomas I. Cutaneous herpes simplex available, it would seem reasonable to apply similar virus infections. Am Fam Physician 1991;43:1655- treatment guidelines to the treatment of herpetic 64. whitlow of the toe. Surgical debridement is gener 2. Gill M], Arlette], Buchan KA. Herpes simplex virus ally discouraged because of the theoretical risk of infection of the hand.] Am Acad Dennatol 1990;22: serious consequences, such as secondary bacterial 111-6. infection or viral encephalitis.!2 Even so, at least 3. Feder HM]r. Herpetic whitlow in an infant without one group favors excising or perforating the over defined risks. Arch DermatoI1995;131:743-4. lying nail for pain relief in the case of an infected 4. Feder HM ]r, Geller RW. Herpetic whitlow of the nailbedY great toe. N Engl] Med 1992;326:1295-6. Although preventing the transmission of HSV is 5. Egan L], Bylander ]M, Agerter DC, Edson RS. Her preferable to either suppressing recurrent infec petic whitlow of the toe: an unusual manifestation of tions or treating existing lesions, there are no cur infection with herpes simplex virus type 2. Clin In rently established methods for the primary preven fect Dis 1998;26:196-7. tion of nongenital HSV infections. Transmission 6. Gill M], Arlette], Tyrrell L, Buchan KA. Herpes frequently occurs through asymptomatic viral simplex virus infection of the hand. Clinical features shedding, which complicates prevention. Strategies and management. Am J Med 1988;85(Suppl 2A): aimed at chemoprophylaxis or isolation of unin 53-6. fected contacts during periods of active lesions are 7. Weisman E, Troncale JA. Herpetic whitlow: a case not effective. Studies are currently underway for report. J Fam Pract 1991;33:516, 520. 16 the development of vaccines for HSV. Although 8. Schwandt NW, Mjos DP, Lubow RM. Acyclovir and the major studies are focusing only on vaccines for the treatment of herpetic whitlow. Oral Surg Oral genital HSV, the research could potentially be ap Med Oral PathoI1987;64:255-8. plied to the development of vaccines for nongenital 9. Feder R\i]r, Long SS. Herpetic whitlow. Epidemi HSV. Patients who are exposed to infected house ology, clinical characteristics, diagnosis, and treat hold contacts and thus are at high risk of becoming ment. Am] Dis Child 1983;137:861-3. infected, such as the patient in this case report, 10. Jarris RF Jr, Kirkwood CR. Herpetic whitlow in would be ideal candidates for vaccination. family practice.] Fam Pract 1984;19:797,800-1. 11. Laskin OL. Acyclovir and suppression of frequently http://www.jabfm.org/ Conclusion recurring herpetic whitlow. Ann Intern Med 1985; Herpetic whitlow of the toe is an uncommon form 102:494-5. of HSV infection with several proposed modes of 12. Gill M], Arlette J, Buchan I(, Tyrrell DL. Therapy transmission. The clinical characteristics are simi for recurrent herpetic whitlow. Ann Intern Med lar to those of herpetic whitlow of the finger. As is 1986;105:631. herpetic infection of the finger, infection of the toe 13. Fitzpatrick TB, Johnson RA, Wolff I(, Polano MI(, is probably often mistaken for a bacterial process. Suunnond D. Color atlas and synopsis of clinical on 28 September 2021 by guest. Protected copyright. Including whitlow in the differential diagnosis for dennatology: common and serious diseases. 3rd ed. all toe infections can improve diagnostic accuracy, New York: McGraw-Hill, 1997. thereby preventing potentially harmful surgical 14. Whitley R], Gnann ]\V]r. Acyclovir: a decade later. procedures and the delay of antiviral therapy in N EnglJ Med 1992;327:782-9. serious infections. 15. Polayes L\1, Arons .MS. The treatment of herpetic whitlow-a new surgical concept. Plast Reconstr Surg 1980;65:811-7. The author thanks Drs. Vicki Copeland and Cookie Schaffranek for their photography and the Good Samaritan Family Practice 16. Stanberry LR. Herpes. Vaccines for HSV. Dennatol Residency faculty for their review of this manuscript. Clin 1998;16:811-6.

Herpetic Whitlow of the Toe 215