That old herpes-simplex virus can even affect finger tips.


Ann, a healthy 7-year-old, was brought to the office for a follow-up after being seen in an urgent care clinic the previous night. Mom said that Ann had an infected finger. It started five days ago as redness and swelling at the cuticle of her right index finger. The redness at the base of the nail became swollen and very painful. It spread down the finger to the first joint and medially toward the finger tip.


After two days there was a blister of tense clear fluid. The blister grew in size and the fluid became a yellowish color that looked like pus. Mom was worried that this could be infected. Ann’s temperature was 99 degrees and never went above that. She seemed otherwise fine. But her finger was painful and mom took her to urgent care clinic to have it checked out.


Mom was told that Ann had an infected finger—a paronychia or bacterial infection. They would need to drain it and put her on antibiotics. Ann freaked out, clenched her fist and would not let anyone look at her finger. Mom decided they would wait and have her seen in our office the next morning. They were there before we even opened.


Ann did not have a fever. Other than her finger she looked just fine. That index finger was swollen and very tender. There was redness of the distal digit extending from the cuticle down to the first joint. It medially involved a third of her finger tip. The redness did not extend across the joint nor was it a deep red one would expect with a bacterial infection. In the center was a tense blister of whitish fluid involving over 50% of the red area. Questioning them further, it seems that she has a habit of biting her nails and always has her fingers in her mouth. With that, I told mom that Ann had Herpetic Whitlow, which is a self-resolving viral infection. Ann was thrilled to learn that we did NOT need to drain it.


Herpetic Whitlow is a localized infection of the fingers caused by the virus herpes-simplex. It is the virus that causes gingiva-stomatitis or cold sores, first described in 1909. Over 60% of Herpetic Whitlow is caused by herpes-simplex virus type I. The rest are caused by herpes-simplex type II (genital herpes). Most children with Herpetic Whitlow are infected with type I herpes for obvious reasons. They will have cold sores in their mouth, and inadvertently have their fingers in their mouth (thumb sucking, finger sucking or nail biting). If there is a break in the skin such as a torn cuticle, they auto-inoculate the finger with the virus.


After an incubation period of 2-20 days the Herpetic Whitlow begins. It starts with redness and swelling, pain and tingling. Then in a few days the vesicle or blister will form. The fluid may start out clear, but then becomes cloudy and resembles pus. Over the next 10-14 days the lesion will slowly resolve, dry out and crust. If it does spontaneously burst the virus is shed. It is contagious until the lesion dries out.


Herpetic Whitlow will resolve within a couple of weeks. The treatment is supportive. Anti-inflammatories are helpful, such an Advil or Motrin as well as ice packs. There are anti-viral medications that can be taken by mouth. These may shorten the healing time but must be started within the first 48 hours of the infection to be effective. Rarely is a patient with Herpetic Whitlow seen this early in the course of their infection.


Drainage is contra-indicated and should be avoided as this may increase the spread of the virus. It may increase the chances of this becoming secondarily infected or may cause more systemic spread of the virus which can be serious. It is wise to cover the infected area to avoid spreading of the virus and to protect the blister so it does not burst. People who were contact lenses must be particularly careful if they have Herpetic Whitlow to avoid spreading the infection to their eyes. They may want to use glasses until the infection has resolved.


I pulled out a dermatology book to show them a picture of Herpetic Whitlow. It looked exactly like Ann’s finger which was reassuring to them both. Ann was ecstatic that we didn’t have to do anything more than cover the finger. I made a friend that day!