Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(2):e2022052 1 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 1. Herpetic whitlow can have ambiguous presentation and is commonly misdiagnosed. 2. Dermoscopic description of herpetic whitlow is characteristic and may help to avoid biopsy or serological test in children. 3. Specific diagnosis is made by PCR, can be aided by cytology. Introduction HSV-1 and 2 infections in children commonly present with fever and gingivostomatitis [1]. Infection of the fingers and toes, due to autoinoculation from asymptomatic salivary car- riers, is known as Herpetic whitlow. Classically, it presents as deep seated, tender, non-purulent, swollen, vesico-ulcer- ative lesions on the finger, usually preceded by a prodrome of numbness, tingling or itching of the affected site [1]. However, atypical presentations may be often misdiagnosed. Timely diagnosis of the condition helps prevent secondary bacterial infection. We report this case to emphasize the der- moscopic features of herpetic whitlow which has never been previously reported. Case Presentation A 10-year-old girl presented with a 4 day history of redness, swelling and blistering of 2 fingers of the left hand. Patient gave a history of similar episode 2 years back over the same location. There was no history of fever, trauma, new medi- cation, friction over the fingertips or any contact with other infectious lesions. On examination there were tense, clear, fluid-filled vesicles arranged linearly over the palmar side of the left thumb and index finger (Figure 1). Draining lymph nodes were not palpable. There were no coexisting mucocu- taneous vesiculation. A clinical diagnosis of herpetic whitlow was made. On dermoscopic evaluation, the lesions were longitudi- nally oriented and the primary lesions rested on a pale base with surrounding bright erythema. The primary lesions ap- peared as relatively pale rings circumscribed by a rim of red dots. The pale lobulated appearance is explained by the for- mation of intraepidermal bullae due to pathogenic ballooning degeneration of keratinocytes and acantholysis. The pallor is also partly due to the presence of vesicular fluid. The red dots 2 Research Letter | Dermatol Pract Concept. 2022;12(2):e2022052 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- ported in the journal. The patient understand that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. References 1. Lieberman L, Castro D, Bhatt A, Guyer F.  Case report: palmar herpetic whitlow and forearm lymphangitis in a 10-year-old fe- male. BMC Pediatr. 2019;19(1):450. DOI:10.1186/s12887-019- 1828-5. PMID: 31752766. PMCID: PMC6868856. 2. Hoyt B, Bhawan J. Histological spectrum of cutaneous herpes infections. Am J Dermatopathol. 2014;36(8):609–619. DOI: 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. Figure 1. Clear, fluid-filled vesicles over an erythematous base arranged in a linear fashion over the thumb and index finger. are due to erythrocyte extravasation seen histopathologi- cally [2]. The thickness of stratum corneum over the palms and soles and the subepidermal location of the vesicle ex- plain why dermatoglyphics are not lost ( Figure 2, A and B). Tzanck smear of blister fluid showed multinucleated giant cells. Gram stain did not reveal any bacterial colonies. PCR assay was positive for HSV-1 virus, confirming the diagnosis. The patient was started on oral acyclovir 200 mg 5 times a day and patient completed a course of 5 days of therapy with complete resolution of skin lesions.