10.5826/dpc.1202a52
text/xml
2160-9381
1898
en
Bikash Ranjan Kar
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermoscopy
Dermoscopic Findings of Recurrent Herpetic Whitlow in a Child
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-05-02
2021-07-19
2022-05-02
2022-05-24
e2022052
Dermatol Pract Concept
Bikash Ranjan Kar
2022/05/02
10.5826/dpc.1202a52
e2022052
Department of Dermatology, IMS and SUM Hospital, Siksha ‘O’ Anusundhan University, Bhubaneswar, India
2160-9381
dermoscopy
en
e2022052
Dermoscopic Findings of Recurrent Herpetic Whitlow in a Child
https://dpcj.org/index.php/dpc/article/download/1898/1574
                       Dermoscopic Findings of Recurrent
                          Herpetic Whitlow in a Child
        Ishan Agrawal1, Bhabani Bhabani Singh Tarini Prasad Singh1, Bikash Ranjan Kar1


1 Department of Dermatology, IMS and SUM Hospital, Siksha ‘O’ Anusundhan University, Bhubaneswar, India



Key words: Dermoscopy, Herpetic whitlow, Viral infection, HSV, Vesicular lesion.
Citation: Agrawal I, Singh BSTP, Kar BR. Dermoscopic Findings of Recurrent Herpetic Whitlow in a Child. Dermatol Pract Concept.
2022;12(2):e2022052. DOI: https://doi.org/10.5826/dpc.1202a52
Accepted: August 5, 2021; Published: April 2022
Copyright: ©2022 Agrawal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Ishan Agrawal, Department of Dermatology, IMS and SUM Hospital, SOA University, Bhubaneswar,
India – 751003. E-mail: ishanagrawal1995@gmail.com




Learning Points                                                          Case Presentation
 1. Herpetic whitlow can have ambiguous presentation and is              A 10-year-old girl presented with a 4 day history of redness,
    ­commonly misdiagnosed.                                              swelling and blistering of 2 fingers of the left hand. Patient
 2. Dermoscopic description of herpetic whitlow is characteristic
                                                                         gave a history of similar episode 2 years back over the same
     and may help to avoid biopsy or serological test in children.
 3. Specific diagnosis is made by PCR, can be aided by cytology.         location. There was no history of fever, trauma, new medi-
                                                                         cation, friction over the fingertips or any contact with other

Introduction                                                             infectious lesions. On examination there were tense, clear,
                                                                         fluid-filled vesicles arranged linearly over the palmar side of
HSV-1 and 2 infections in children commonly present with                 the left thumb and index finger (Figure 1). Draining lymph
fever and gingivostomatitis [1]. Infection of the fingers and            nodes were not palpable. There were no coexisting mucocu-
toes, due to autoinoculation from asymptomatic salivary car-             taneous vesiculation. A clinical diagnosis of herpetic whitlow
riers, is known as Herpetic whitlow. Classically, it presents            was made.
as deep seated, tender, non-purulent, swollen, vesico-ulcer-                  On dermoscopic evaluation, the lesions were longitudi-
ative lesions on the finger, usually preceded by a prodrome              nally oriented and the primary lesions rested on a pale base
of numbness, tingling or itching of the affected site [1].               with surrounding bright erythema. The primary lesions ap-
However, atypical presentations may be often misdiagnosed.               peared as relatively pale rings circumscribed by a rim of red
Timely diagnosis of the condition helps prevent secondary                dots. The pale lobulated appearance is explained by the for-
bacterial infection. We report this case to emphasize the der-           mation of intraepidermal bullae due to pathogenic ballooning
moscopic features of herpetic whitlow which has never been               degeneration of keratinocytes and acantholysis. The pallor is
previously reported.                                                     also partly due to the presence of vesicular fluid. The red dots




Research Letter | Dermatol Pract Concept. 2022;12(2):e2022052                                                                          1
                                                                            Differential diagnosis of herpetic whitlow includes
                                                                        bacterial infective whitlow, friction blister, suction blister,
                                                                        bullous impetigo, erythema multiformae, coxsackie virus in-
                                                                        fection [1]. Herpetic whitlow is a self-limiting infection and
                                                                        incision and drainage are not indicated, as they are done in
                                                                        bacterial paronychia, due to the risk of viremia and second-
                                                                        ary bacterial infection. Treatment with antiviral decreases
                                                                        the duration of symptoms of viral shedding.


                                                                        Conclusions
                                                                        Diagnosis of herpetic infection is often made clinically. How-
                                                                        ever, it resembles many other infectious and non-infectious
                                                                        dermatoses [1]. Our report documents the dermoscopic fea-
                                                                        tures of herpetic whitlow, which has never been previously
                                                                        reported and can aid in early diagnosis.
                                                                            Consent: A written consent was taken from the guardian
                                                                        for using the image and other clinical information to be re-
Figure 1. Clear, fluid-filled vesicles over an erythematous base        ported in the journal. The patient understand that their name
­arranged in a linear fashion over the thumb and index finger.
                                                                        and initials will not be published and due efforts will be made
are due to erythrocyte extravasation seen histopathologi-               to conceal their identity, but anonymity cannot be guaranteed.
cally [2]. The thickness of stratum corneum over the palms
and soles and the subepidermal location of the vesicle ex-
                                                                        References
plain why dermatoglyphics are not lost (­Figure 2, A and B).
Tzanck smear of blister fluid showed multinucleated giant                1. Lieberman L, Castro D, Bhatt A, Guyer F. Case report: palmar
cells. Gram stain did not reveal any bacterial colonies. PCR                herpetic whitlow and forearm lymphangitis in a 10-year-old fe-
                                                                            male. BMC Pediatr. 2019;19(1):450. DOI:10.1186/s12887-019-
assay was positive for HSV-1 virus, confirming the diagnosis.
                                                                            1828-5. PMID: 31752766. PMCID: PMC6868856.
The patient was started on oral acyclovir 200 mg 5 times a               2. Hoyt B, Bhawan J. Histological spectrum of cutaneous herpes
day and patient completed a course of 5 days of therapy with                infections. Am J Dermatopathol. 2014;36(8):609–619. DOI:
complete resolution of skin lesions.                                        10.1097/DAD.0000000000000148. PMID: 25051039.




Figure 2. (A,B) Primary lesion over a pale base and surrounding erythema. Pale rings circumscribed by rim of red dots and a central red hue,
with no loss of dermatoglyphics.



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