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Clinical Summary

Primary or recurrent HSV infection presents as grouped vesicles on an erythematous base. Recurrent HSV is typically less severe than the primary infection. A prodrome is frequently noted with fever, malaise, anorexia, and regional lymphadenopathy. The vesicles progress to pustules and crusted erosions. They heal over 2 to 3 weeks. Mucocutaneous involvement of the mouth and lips are the most common sites. Herpetic whitlow is a painful HSV infection of a distal finger seen primarily in children and adolescents. Herpes gladiatorum spreads via direct skin-to-skin contact in sports such as rugby and wrestling.

Management and Disposition

Oral antivirals in addition to analgesics and antipyretics are useful. To be most effective, antivirals should be started within 72 hours of eruption or during the typical prodrome. Immunocompromised patients may require admission and IV antivirals. Dermatology consultation is recommended for complicated presentations.


  1. Always wear protective gloves when examining open wounds; herpetic infections are an occupational hazard in the medical and dental professions.

  2. Wrestlers (or participants in any skin-to-skin contact sport) with vesicles and ulcers may not participate in organized sports until completely healed. Consult the National Collegiate Athletic Association (NCAA) and the National Federation of State High School Associations (NFHS) return-to-play guidelines.

  3. Recurrent, same-site infections on the fingers should alert the clinician to consider herpetic whitlow. These infections are often misdiagnosed as cellulitis, blistering dactylitis, or paronychia.

FIGURE 13.33

Herpetic Whitlow. Painful, grouped, confluent vesicles and an erythematous base on the distal finger. (Photo contributor: Selim Suner, MD, MS.)

FIGURE 13.34

Herpetic Whitlow. Vesicles on an erythematous base. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 13.35

Herpes Gladiatorum. Primary herpes gladiatorum in a wrestler. Note the varied stages of lesions, from vesicular to dried crusts. (Photo contributor: Lawrence B. Stack, MD.)

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