|Herpetic Witlow. ( photo: Epmonthly|
What is a herpetic whitlow?
Herpetic whitlow is a painful infection of one or more fingers, caused by a virus called herpes simplex virus and mostly affecting the end part of the fingers.
What are the common causes?
It is commonly caused by exposure to body fluid containing the virus (HSV), such as the fluid from the blisters of cold sores in the mouth or affected genital areas. Autoinoculation – easy transfer of the virus from one body part affected by herpetic lesions, e.g. genital or mouth herpes, to the unaffected parts (that is the fingers in this case) can cause herpetic whitlow. Also, individuals with low immunity are at a higher risk of this infection – reactivation of old infection and involvement of internal body organs (systemic complications) – all because of the inability of the body to mount an appropriate level of resistance against the virus.
Are there different types?
Yes, there are different types, depending on the variant of the virus responsible. There are many variants of the HSV. The variants responsible for herpetic whitlow are HSV-1 and HSV-2 in about two-third and one-third of cases, respectively.
Is it common among a particular age bracket?
It can affect both adults and children, albeit in different ways. In children, HSV-1 is more commonly responsible, involving the fingers. It is due to a transfer from the initial mouth or gum lesions (herpetic gingivostomatitis) as a result of finger-sucking or thumb-sucking behaviour, and in children with genital lesions (herpes labialis).
In the adult population, it is due to the transfer from the genitals of adults with herpes infection (autoinoculation); hence, the commoner virus in such cases is HSV-2, which is the common cause of genital herpes.
However, HSV-1 is also common in healthcare professionals due to unprotected exposure to infected fluid emanating from the mouth of the affected patients. This easily can be prevented by use of gloves and observing universal fluid precautions religiously.
How does it manifest in children and adults?
It presents as extremely painful, crop of fluid-filled and grouped swelling of the involved finger. However, in contrast to a condition called felon (which could sometimes look similar in appearance as herpetic whitlow), the pulp space usually is not tensely swollen. We may also find pre-existing herpetic lesions in the mouth or genitalia.
What are the general (early and late) symptoms?
The (infected) individual may experience being generally unwell with some fever days before the skin manifestation. The individual would experience pain and fluid-filled swelling of a finger, especially the thumb and index fingers. The late symptoms may be severe and include spread to internal organs leading to infection of the internal organs (sepsis) and brain involvement (encephalitis) especially in people with low immunity.
How is it diagnosed?
Medical doctors do not usually require any investigation to make the diagnosis of herpetic whitlow. The diagnosis is usually clinical; it is based on a patient’s complaint and what the clinician observes. In children, observation of concurrent cold sore in the mouth is almost indicative.
In adults, occupational risk factors or observation of concurrent oral or genital herpes lesions should strongly suggest the diagnosis. Occasionally, we do undertake definitive diagnostic testing such as Tzanck test, viral cultures, serum antibody titres, fluorescent antibody testing, or DNA hybridisation, Polymerase Chain Reactions (PCR) and Immunofluorescent microscopy.
How can it be treated?
The treatment is usually aimed at relieving the symptoms and preventing the spread. Oral (tablets) and topical (cream) anti-viral medications can be beneficial. Sometimes, we use antibiotics in individuals with combined bacterial infections. The tense vesicles may be popped by clinicians to help ameliorate symptoms, and surgical operation of the fingernail may be deployed for the same purpose in cases involving the space underneath the nails (subungual space).
What are its psychological or physical effects on sufferers?
The physical effects are mainly related to combined or super-imposed bacterial infection or infection resulting from mistaken surgical drainage due to incorrect diagnosis of this viral infection as a paronychia, which is a bacterial infection.
Other physical impacts may include severe pain, delayed healing, bacterial infection combined with the herpetic whitlow, and, rarely, systemic spread to the brain causing herpes encephalitis. Herpetic whitlow, if untreated, can cause severe brain infection. The psychological impacts vary from individuals and include inability to use the finger or entire hand, work-related illness, loss or reduction of income, societal stigma, especially if there is genital involvement in adults and attendant consequences.
There is a myth that when a person with a whitlow-infested finger inserts the affected finger in the private part of a woman, it would be cured. Is that true?
No, it is not true. This kind of behaviour could lead to spread of the disease to the lady and increased severity of the disease (or pain) due to the involvement of the lining of the private area.
How best can herpetic whitlow be prevented?
HSV-1 in healthcare professionals can be prevented using gloves and observing universal fluid precautions religiously. If already infected, they should keep their finger clean using antiseptic and covered with a dressing. Individuals should keep their affected fingers away from the genitals during intercourse and take pain-relief medicine to ameliorate the pain. It is important not to touch the affected finger too often because the infection can spread easily.
Infected persons should not touch other parts of their body or other people with the finger. They should not try to drain the fluid by themselves because this can cause the infection to spread. It is also advised to use contact lenses to prevent the spread of the infection to the eyes.