A consultant dermatologist, Dr Ronke Edun, discusses whitlow and its management in this interview with EMMANUEL OJO
What is whitlow?
Whitlow is an inflammation or infection of the skin around the finger nail or toe nail, basically. It can occur as a result of infection or sometimes trauma or an injury to the finger. The infection can be acute or chronic. Acute means that the duration is less than six weeks while chronic means that the condition goes on for more than six weeks.
How does the condition present itself?
The area around the nail is usually swollen and painful; and there might be pus, usually found in people that cut their cuticle as the cuticle is supposed to cover that area. The cuticles are the skin around the nails. They are meant to protect that area but when they are cut off, that area can be exposed to infection.
The symptoms vary, depending on whether it is acute or chronic whitlow. In the acute form, there is a very painful sensation on the skin around the nails, the nail bed and the cuticles of the nail. There will be a change in the colour of the skin. It can be red or white. It will also be swollen. In some patients, there might be fever. Fever simply refers to a state when the body temperature is higher than normal. There will be chills and rigors. This simply refers to a state of shivering.
For the chronic form, the pain might not be there but the skin will be swollen and filled with pus.
What are the common infectious agents causing the condition?
Bacterial causes are the commonest, however, in some patients, it can be due to viruses and these viruses are same viruses that cause cold sore in the mouth – the herpetic virus. People with cold sore in their mouth and have the habit of always biting their nails or cuticles could end up developing whitlow. Fungi can also be a cause. So, basically, organisms like bacteria, virus, fungi can cause whitlow. Those are the causative agents.
Whitlow appears easy to recognise even for a layman. Will it be compulsory to have it diagnosed in the hospital?
Diagnosis is very easy and that’s why it’s easy to manage. Any doctor can diagnose it; it doesn’t have to be a dermatologist except in complicated cases but when I say any doctor, I mean any competent doctor.
What is the diagnosis approach in the hospital?
Diagnosis is clinical. Take the history of the finger, maybe there’s a trauma in the hand or infection. Clinically, there will be pain, you’ll see the cut and the area of specification around the nail.
What are the possible complications?
Whitlow can lead to serious hand infection in which the whole hand will be infected. This is called cellulitis, meaning that more than just the finger will be affected. The whole hand can be infected and it could spread to the whole limb if the patient has a background immune suppression. Whitlow should be watched out for in patients with immune suppression because it can result to a full-blown infection.
Another complication is that after healing, it can disfigure the nail. This is referred to as nail dystrophy. There could be change in the colour of the nail, it might just turn black or brown instead of white, then the shape as well can change.
After the infection has resolved, the nail can start growing abnormally, deviating from the normal shape. Whitlow can result in permanent deformity of the nail or finger. Sometimes, some nails don’t even grow again. In the course of the infection, especially in chronic cases, the nail might go off and might not grow again.
This can affect the total quality of life. The patient will start hiding the finger, wouldn’t be proud to expose that hand or part of the body to the public anymore.
Who are the people mostly at risk of having whitlow?
One of the risk factors is biting of nails, especially in people that have cold sore in their mouth. The virus can enter the bitten skin of the finger and cause whitlow. Also, in children, especially those that suck their fingers, they could develop whitlow. Manicure and pedicure can also cause it, especially when the instruments are not sterilised or when more cuticle than necessary is removed in the course of trimming the nails.
Then I have also noticed of recent that the fixing of artificial nails can also cause whitlow. Women who always fix nails could be predisposed to whitlow.
Then, people whose jobs require that their hands are always wet or moist are also at risk of having whitlow. Lastly, immune-suppression is also a risk factor. Anything that can cause the immune system to be suppressed like cancer or HIV drugs will predispose a person to having whitlow.
Is whitlow contagious?
Yes, it is infectious depending on the organism. More often than not, if it’s of viral etiology, it can be transferred through handshake or by contact with body fluids, especially if it’s caused by the herpes virus.
How is it treated?
The treatment is clinical. Every other thing that you are doing is just to show a lab evidence of the infection. You test the sample or culture to determine the exact causative agent, whether it is bacteria, virus or fungi. But while doing that, antibiotics or antibacterial drugs are administered, depending on the tentative diagnosis based on the symptoms seen on physical examination and history. And for the pain, analgesics are given. But first of all, you have to completely drain the abscess or the pus. In some cases, the nail will be removed. If the nail is removed medically, there is a possibility for the nail to grow again but in a situation where it’s as a result of complication, it might not grow again.
What are some of the common misconceptions about treatment of whitlow?
Well, I have heard people say that in acute cases, you can soak the finger in warm water but I don’t advise that because even the fact that your hand is moist is a risk factor.
As I said earlier, constant exposure of the hand to water or moisture is a risk factor.
How long does it take to heal?
Healing is usually an individual thing. It takes between seven to 10 days to heal. It depends on the person. If one has whitlow and still dips the hand in water and do things that help the organism to thrive, healing won’t happen on time. Healing also depends on the suitability or efficacy of the antibiotic chosen, if it’s a whitlow caused by bacteria. Healing depends on individuals; there’s really no estimate of how long. But one thing is that one has to rest that finger, take medication and eat good diets for healing to be complete.
Can whitlow resolve by itself without medical intervention?
It depends on the kind of organism that caused the infection. Some organisms are usually very mild such that the person’s innate immune system is able to fight the infection but in some cases, the bacteria multiply rapidly such that the body is not able to tackle it. In such a case, it has to be treated.
In some cases, the skin is swollen, there is pain and few days later, the whole thing goes away but in other cases, you just have to treat it. But there are times too when people do nothing to it and it heals. In some other cases, you might just have to take some time off so that whatever medication is being used would have effect. In most cases, if it persists for one to two weeks, then one has to see a doctor because there could be complications. It could be that the drugs given are not the right drugs that the virus or bacteria are responsive to. This will demand a change of drugs. In some cases too, anti-tetanus might be given if the person has not completed the immunisation because it can be a source of infection which could lead to tetanus.
You mentioned that improper management of whitlow can result in some complications. Is the condition capable of causing death?
(Laughs) I laugh because, honestly, death is not cheap. It’s not likely to lead to death except in cases of negligence. But the pain is usually severe that one cannot ignore and would have to attend to it.
Whitlow is not necessarily managed by a consultant or dermatologist. Any doctor who went through the medical school can manage the situation. It’s only in cases of complications where, for example, the entire nail bed is affected and there’s a need to remove the nail that the expertise of a consultant dermatologist or a plastic surgeon might be required. A primary health care centre can even manage an uncomplicated whitlow. So, it’s rare for it to lead to death. Death is usually not a complication of whitlow.
