The index finger and thumb are most often involved,3 although unusual sites such as the great toe have been reported.4 Herpetic whitlow may present with a prodrome of tingling, itching, and burning prior to vesicle formation in 24 hours. The lesions are initially papules, followed by vesicles on an erythematous base. In two to seven days they often rupture with crusting. Pain may be severe enough to require narcotic analgesia. Multinucleate giant cells may be seen on a Tzanck smear prepared from the base or margins of the vesicles.
Treatment includes symptomatic relief with oral analgesics and cool compresses.
Acyclovir, an antiviral medication active against herpes, decreases viral excretion, new lesion formation, and promotes rapid healing. It is beneficial if started in the prodromal phase, or within two days of vesicle formation. Unfortunately, it has not been proven to influence the recurrence rate.2 Dosing in primary infections is 200 milligrams orally five times daily for 7-10 days. Dosing in recurrent infections is 200 milligrams orally five times daily, or 800 milligrams twice daily, for 5 days.6 Topical and intravenous preparations of acyclovir are also available. The vesicular fluid is highly infective.