Cause: HSV1 or HSV2 (usually from contact with infected oral lesions)
Affects the fingertip (digital infection)
Risk Factors: Health care workers (e.g., dentists), children sucking fingers, immunocompromised patients

Diagnosis

Primary infection: Confirm with PCR swab
Recurrent flares: Typically diagnosed clinically, as lesions recur in the same spot

Note:

Direct fluorescence antibody (DFA) testing is an alternative for confirmation in unclear cases
Tzanck smear is outdated but shows multinucleated giant cells

Treatment

1ry Infection (Primary HSV)

If minor:
- Symptomatic relief with topical anaesthetic gel q2h PRN (e.g., anaesthetic mouthwash in hospital)
- Analgesia, ensure adequate hydration
If severe:
- Oral antiviral (e.g., valaciclovir 1 g BD for 7 days)

2ry Infection (Recurrent HSV)

If minor:
- Topical antiviral (e.g., acyclovir 5% cream q4h for 5/7) OR oral famciclovir 1.5 g stat
If severe:
- Oral famciclovir 1.5 g stat
Suppressive therapy:
- For frequent disabling recurrences or complications (e.g., erythema multiforme), use valaciclovir 500 mg daily for 6 months
Early treatment initiation during the prodromal stage (tingling/burning) can significantly reduce lesion duration and severity

Non-Pharm Management

Advise patients to avoid direct contact with the lesion to reduce transmission
Educate on the recurring nature of the condition
Highlight triggers that provoke flare-ups (trauma, sun exposure, viral infections, stress)
Tingling or burning is an early sign of a flare
Herpetic whitlow caused by HSV1/2 can be treated with oral valaciclovir for 1 year and acyclovir cream for recurrent 2ry infections
Advise avoidance of sharing utensils, lip products, or towels during active outbreaks
Emphasise hand hygiene to minimise autoinoculation or spread

HSV (Herpes Simplex Virus)

Common viral infection caused by HSV-1 (oral-labial lesions, herpetic whitlow) or HSV-2 (often genital, but can infect other sites)
Primary infection typically more symptomatic than recurrences
Transmitted via direct contact with lesion fluid or mucosal secretions

Oral HSV (Herpetic Gingivostomatitis)

Herpetic Whitlow (Finger Infection)

Caused by HSV-1 or HSV-2 through direct contact with infected oral or genital lesions
Infection of the fingertip or nail bed
Risk factors: healthcare workers (dentists), children with thumb-sucking habit, immunocompromised patients
Presents with painful vesicles or ulcers on the finger, local swelling and erythema

Diagnosis

Primary Infection
- PCR swab from lesion is the gold standard for confirmation
- Direct fluorescent antibody (DFA) testing can be used if PCR unavailable
- Tzanck smear is outdated (reveals multinucleated giant cells but lacks specificity)
Recurrent Lesions
- Usually diagnosed clinically, lesions recur in the same site
- Serological tests (HSV IgG/IgM) may help distinguish HSV-1 vs HSV-2, though not routinely required

Management

Primary HSV Infection
- If mild: supportive care with topical anaesthetic gel or mouthwash, regular analgesia, adequate hydration
- If severe or extensive lesions: oral antivirals (e.g. valaciclovir 1 g BD for 7 days)
- Consider IV antivirals in severe immunocompromise or disseminated infection
Recurrent HSV Infection
- If mild or limited: topical aciclovir 5% cream q4h for 5 days or one-off oral therapy (famciclovir 1.5 g stat)
- If severe or frequent: oral famciclovir 1.5 g stat can shorten the episode
- Suppressive therapy with valaciclovir 500 mg daily for ≥6 months if recurrent episodes are frequent or complicated (e.g. erythema multiforme)
- Early initiation during the prodromal phase (tingling or burning) significantly reduces lesion severity and duration
Herpetic Whitlow
- Oral antiviral (valaciclovir or famciclovir) if pain or extensive involvement
- Keep lesion covered, practise meticulous hand hygiene
- In immunocompromised individuals, consider longer antiviral courses
Non-Pharmacological Measures
- Avoid direct contact with active lesions (no sharing utensils, lip balms)
- Identify triggers for recurrent flares (trauma, UV exposure, stress, immunosuppression)
- Emphasise hand washing to prevent autoinoculation (e.g. from lip to finger or eye)
- Advise patients to watch for ocular involvement (urgent ophthalmology referral if suspected)

Complications

Local
- Secondary bacterial infection of lesions
- Severe pain or dehydration if lesions in oropharynx
Neurological
- Encephalitis (HSV is the most common sporadic encephalitis cause)
- Aseptic meningitis
- Bell’s palsy (rare)
Haematological or Mucocutaneous
- Erythema multiforme triggered by HSV
Other
- Disseminated infection in immunocompromised hosts

Notes:

Early recognition of primary infection can prompt timely antiviral therapy and reduce complications
Recurrent cold sores are very common, and patient education on prodromal symptoms plus early antiviral use is crucial
Herpetic whitlow in healthcare workers emphasises need for gloves and protection
Children with gingivostomatitis may require careful hydration management
Investigate severe or atypical presentations for immunodeficiency or other underlying pathologies

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