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The Informed Parent

Herpetic Whitlow

by Louis P. Theriot, M.D., F.A.A.P.
Published on Dec. 13, 2004

It was a Monday morning, and the office had not yet opened when one of the early nurses pulled into the parking lot. She noticed a car already parked and a mother waiting by the door with her child in her arms. She immediately turned off the ignition and raced toward the mom to see if it was an emergency. The mom sensed the nurse’s concern and motioned to her that everything was all right. “It’s okay,” she said. “I’m just probably overreacting. But I don’t know if this should wait until I can have an appointment.” Her 18-month-old daughter had a red, swollen thumb.

I pulled into the lot early, primarily because it WAS a Monday, and Mondays are usually like that! More cars than usual were already here. Entering the office my nurse told me that Mrs. K. was here with her daughter who had a horribly infected thumb. The nurse was instructed to put them into a room immediately. I was pleased to see that Annie did not have a fever and was quite comfortable sitting on mom’s lap.

Mrs. K. told me that she first noticed Annie’s thumb becoming a little swollen on Saturday night. However, it didn’t seem to bother her and there had been no trauma. Mom decided to just watch it. It was considerably swollen the next morning with a reddish hue around the nail. By Sunday night the redness had intensified, as had the swelling. She now could tell that it bothered Annie...especially since this was the thumb she sucked to help fall asleep. “I didn’t want to panic,” she said in an apologetic voice. “But it was a rough night. I didn’t want to bother the on-call doctor, and figured I’d make an appointment first thing in the morning.” She went on to say that when she checked on Annie this morning the end of her thumb looked like a little tomato, swollen and red. What concerned her the most was that there was a pocket of pus at the base of the nail bed, near the cuticle.

Peter was a 12-year-old boy in excellent health. He had just had his yearly physical a few weeks ago and had gotten a clean bill of health. The appointment today was for an infected index finger. Like Annie, he did not have a fever nor did he appear to be ill. The end of his index finger was swollen and red. He, too, had a little pocket of pus at the base of the nail bed. The swelling was limited to the distal digit of his finger, which did not extend beyond the first joint. It was quite tender and painful to touch. Upon examining his fingers it was obvious that he bit his nails.

Peter’s mom told me that this had all occurred over a couple of days. Then she informed me that it had been her intent to sterilize a needle and drain out the pus. But Peter wouldn’t let her get near him with the needle. As she told me about this, Peter tucked his hand under his arm, just for safe keeping.

Both Annie and Peter had a fairly common infection caused by Herpes simplex, the same virus that causes canker sores. This infection of the nail bed is called herpetic whitlow. It is a self-limiting infection that usually resolves without treatment. It will run its course in five-to-ten days. Both of the children probably harbored the herpes virus in their mouths from a current or recently passed oral infection with herpes. Annie most likely infected herself by sucking her thumb, and Peter did the same by biting his nails. This infection does not require antibiotics. And, it is CONTRAINDICATED to drain the little pocket of pus at the nail bed. I told Peter’s mom that this could have caused a dissemination of the virus and made matters worse. Peter breathed a sigh of relief that he had been vindicated in his refusal to allow his finger to become fodder for his mom’s minor surgery. “See mom,” he said in a smug voice. “I told you so!” The smugness left his face when I informed him that the reason his finger got infected was probably because he was biting his nails. And, we were going to talk about ways of getting him to stop.

While herpetic whitlow is not an uncommon infection, bacterial infections of the fingers do occur as well. These are much more serious and should not be treated lightly. Early antibiotic use and possible drainage are critical. It would be impossible to differentiate between the two without examination. Early in the course these infections can look very similar. The best advice is that if there seems to be an infection of the end of the finger, have it checked by a physician.

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