SAN FRANCISCO Mothers who bite their babies' nails instead of clipping or filing them can spread herpesvirus infection unwittingly, Dr. Meg C. Fisher warned.
Biting off infant nails "is a very common thing, particularly among Hispanic mothers or any young mothers who are afraid to use nail clippers," said Dr. Fisher, chief of pediatrics at Monmouth Medical Center, Long Branch, N.J. Advise parents who are afraid to use clippers on the nails of tiny fingers and toes to use an emery board, but not to bite, she suggested at the annual meeting of the American Academy of Pediatrics.
Herpesvirus infection is ubiquitous among adults and almost always asymptomatic. Most people infected with herpes don't know they've got the virus. Carriers shed the virus when herpes sores develop but also intermittently at times when no sores are present.
When a herpetic whitlow developsa painful herpes infection typically on the fingers or around fingernailsit may be misdiagnosed as a bacterial infection because of the lesion's disturbingly dark coloring. "It really does look like it's gangrenous. These lesions look horrible" yet distinctive, once you're familiar with them, Dr. Fisher said. "There's nothing else that turns your finger black like that."
She described a 9-month-old patient who was treated for a week with cephalexin for presumed bacterial infection in a finger, with no improvement. The lesion was a herpetic whitlow caused by infection from her mother biting the child's nails.
Treating it with acyclovir probably doesn't make sense unless you catch the lesion early, she said. "This will get better if you do nothing. Wait it out."
Warn parents that some herpetic whitlows recur. Treating such a lesion with acyclovir in the early phases might shorten its duration if parents bring it to your attention within the first couple of days.
"The one thing you don't want to do is to send them to a surgeon" who will be tempted to incise and drain the lesion, thinking it's a bacterial infection, she added. That can lead to superinfection with staphylococcus or other bacteria in addition to the herpetic whitlow. Even worse, a herpetic whitlow mistaken for hand cellulitis usually results in the patient being admitted to a hospital "and gets a hand surgeon or orthopedic surgeon excited," often leading to an unnecessary procedure, Dr. Fisher said. "If you can, don't admit them [to the hospital]. If you want to give IV therapy, give IV acyclovir. You don't need antibiotics."
Prophylactic therapy might make sense for patients who are prone to herpetic whitlows. Teenage wrestlers, for example, may need prophylaxis during the competitive season. Prescribing valacyclovir or famcyclovir, each of which requires fewer daily doses than acyclovir, may be the best choice to ensure compliance in these cases.
Advise athletes on herpes prophylaxis that the medication must be taken daily, and that care should be taken not to get dehydrated, which could damage the kidneys, she said. Tell the patient that ongoing treatment could cause his or her viral isolate to develop drug resistance.
Some sports coaches can get carried away with the idea of prophylaxis, Dr. Fisher added. A summer wrestling camp in her area informed parents in early 2007 that every student should be taking acyclovir and fluconazole to avoid herpes and fungal infections.
Local pediatricians called Dr. Fisher, asking if she thought this was a good idea. "I said, 'No.' This is the kind of pressure that these elite athletes are getting," she said. The pediatricians she spoke with all refused to prescribe the drugs for uninfected athletes, and none of the students were excluded from the camp, as far as she knows.
She said she advises coaches or athletes to disinfect wrestling mats with bleach in a 1:100 dilution in water. That kills the herpesvirus and common bacteria.