Eczema herpeticum is a rare, painful skin rash usually caused by the herpes simplex virus HSV. HSV-1 is the virus that causes cold sores, and it can be transmitted through skin-to-skin contact. The condition was initially called Kaposi varicelliform eruption, after the person who first described it and thought the eruption looked like chickenpox. EH most commonly affects infants and young children who have eczema or other inflammatory skin conditions. But it can also affect adults.
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Eczema herpeticum, also known as a form of Kaposi varicelliform eruption caused by viral infection, usually with the herpes simplex virus HSV , is an extensive cutaneous vesicular eruption that arises from pre-existing skin disease, usually atopic dermatitis AD.
Eczema herpeticum can be severe, progressing to disseminated infection and death if untreated. Detailed history taking and characteristic cutaneous findings can help clinicians make an accurate diagnosis. A 4-year-old girl whose medical history was remarkable for chronic AD since infancy experienced fever, chills, and rhinorrhea for 6 days. Multiple chronic eczematous lesions with erosions and excoriations were noted over the frontal region and the cheeks.
She was taken to a local clinic, where impetigo and acute upper respiratory tract infection were initially considered. A topical antibiotic ointment and other medications were prescribed to relieve the symptoms, but the fever persisted.
Two days later, she experienced general malaise, poor activity, periorbital swelling, and purulent discharge from the cutaneous lesions; therefore, she was brought to our pediatric outpatient department for evaluation. She had received vaccination as scheduled but had not received vaccination in the past 6 months.
On initial examination, the patient had a fever, with a temperature of Multiple grouped punched-out ulcers were noted with local dissemination over the frontal, periorbital, and perioral areas and cheeks Figure 1. Furthermore, secondary impetiginization was observed around the mouth.
However, no palpable lymphadenopathy was found. Multiple grouping punched-out ulcers with local dissemination over the frontal, periorbital and perioral areas and cheeks, with secondary impetiginization. A dermatologist consultant diagnosed eczema herpeticum with secondary impetiginization, which was confirmed by a Tzanck test for multinucleated giant cells Figure 2 and virus isolation HSV The patient was prescribed systemic acyclovir.
An ophthalmologist diagnosed nonspecific conjunctivitis without herpetic keratitis. Tzanck smear from scraping of vesicle base of patient, showing multinucleated giant cells. Herpes simplex virus, a member of the double-stranded DNA Herpesviridae family, can infect the epidermis owing to impaired skin protective function such as in AD.
Eczema herpeticum is a secondary viral infection usually caused by HSV either type 1 or type 2 that concomitantly occurs with skin conditions like AD, psoriasis, eczema, irritant contact dermatitis, burns, and seborrheic dermatitis. Initially, the involved skin might show erythematous changes presenting as small, monomorphic, dome-shaped papulovesicles that rupture to form tiny punched-out ulcers overlying an erythematous base.
Patients often present with herpetic vesicles over an extensive mucocutaneous surface, most often the face, neck, and upper trunk. Patients might have accompanying symptoms like fever, malaise, and lymphadenopathy.
The virus is presumably spread from a recurrent oral HSV infection or asymptomatic shedding from the oral mucosa. Just like other HSV infections, eczema herpeticum can recur. Patients might present with localized HSV infection in previously involved areas. Secondary bacterial infection, mostly due to S aureus , often occurs because of the inflammatory and extensive nature of the process. Early diagnosis of eczema herpeticum can prevent or minimize complications. The criterion standard for diagnosis of HSV infection is virus culture.
In our case, the final virus isolation confirmed our diagnosis. The quality of the swab and culture techniques affect the specificity and sensitivity of virus culture. The microscopic finding of a Tzanck test for multinucleated giant cells can confirm a herpes virus infection and provide rapid diagnosis. Although it is a very easy and quick bedside test, its specificity and sensitivity depend on the operator.
The clinical manifestation of eczema herpeticum is characteristic; however, it can be confused with impetigo, eczema vaccinatum, and primary varicella infection 7 Table 1 1 , 2 , 5 , 8. Eczema herpeticum with secondary staphylococcal infection is a common occurrence that might be misdiagnosed as impetigo, leading to delay in treatment with acyclovir.
Misdiagnosis of eczema herpeticum can lead to severe complications, such as herpetic keratitis and death. Sudden appearance of papulovesicular lesions with punched-out, crusted ulcers in chronic dermatitis caused by herpes simplex virus. Accompanying symptoms include fever, malaise, and lymphadenopathy 2 , 5. Recent history of smallpox vaccination or contact with an individual who received vaccination recently.
Papules, vesicles, umbilicated pustules, or erosions at the site of active dermatitis or previous eczema lesions. Eczema vaccinatum is fatal when it leads to supraepiglottic edema 2 , 5.
Highly contagious superficial skin infection that mostly affects children aged 2 to 5 y. Lesion manifests as a single red papule or macule that quickly becomes a vesicle and an erosion. Subsequently, the content dries, forming honey-coloured crusts. Infection commonly resolves spontaneously 8. Primary varicella infection, also known as chickenpox, is caused by the varicella-zoster virus.
Initial exanthema consists of disseminated pruritic erythematous macules that progress beyond the papular stage, forming clear, fluid-filled vesicles like dewdrops on a rose petal 1. The main treatment of eczema herpeticum is acyclovir, which is also approved for oral use in patients younger than 18 years of age.
For patients with severe disease and immunocompromised patients, systemic antivirus medications and hospitalization are recommended. Owing to the common occurrence of secondary infection with bacteria such as S aureus , prophylactic antibiotics eg, cephalexin, clindamycin, doxycycline, or trimethoprim-sulfamethoxazole should also be administered depending on the geographic susceptibilities.
Timely and accurate diagnosis of eczema herpeticum at initial presentation is very important. In the case of our patient, eczema herpeticum was initially misdiagnosed as impetigo. Antibiotic treatment is insufficient, and progressive eczema herpeticum might cause blindness and even death.
Feye et al 11 presented a case of a year-old man who developed a burning vesicular rash and a chronic skin condition over his back and chest. He also complained of a severe burning sensation and watering in both eyes.
At this juncture, specific treatment with intravenous and topical ophthalmic acyclovir resulted in regression of eczema herpeticum and keratitis. Feye and colleagues 11 emphasized that this condition was a medical emergency and that physicians should recognize such diseases early to avoid ophthalmologic and life-threatening complications.
Atopic dermatitis is the most common diagnosis in the outpatient department for pediatric dermatology. Impaired protective skin function facilitates HSV infection. Patients should be carefully examined for secondary herpes virus infection owing to the high mortality rates associated with it. Secondary bacterial infection is a common complication. Early awareness of eczema herpeticum and prescription of systemic antiviral medication are very important.
Consultation with an ophthalmologist is also required for diagnosing herpes keratitis. In chronic dermatitis, physicians should be aware that grouped and locally disseminated papulovesicular lesions with punched-out ulcers indicate the possibility of eczema herpeticum.
Eczema herpeticum, an extensive and pronounced vesicular and ulcerative eruption that appears with an underlying chronic skin disease, leads to potential blindness and even mortality. Endogenous and exogenous factors contribute to the defective epidermal defence barrier function in patients with atopic dermatitis, which makes patients more susceptible to cutaneous infection.
If the lesions involve periorbital areas, consultation with an ophthalmologist is required. Early diagnosis of eczema herpeticum and immediate systemic antiviral therapy can minimize the severe and lethal complications. Competing interests. National Center for Biotechnology Information , U. Journal List Can Fam Physician v. Can Fam Physician. Author information Copyright and License information Disclaimer.
This article has been cited by other articles in PMC. Case A 4-year-old girl whose medical history was remarkable for chronic AD since infancy experienced fever, chills, and rhinorrhea for 6 days. Open in a separate window. Figure 1. Figure 2. Table 1 Differential Diagnosis of eczema herpeticum. DIAGNOSIS CLINICAL FEATURES Eczema herpeticum Sudden appearance of papulovesicular lesions with punched-out, crusted ulcers in chronic dermatitis caused by herpes simplex virus Accompanying symptoms include fever, malaise, and lymphadenopathy 2 , 5 Eczema vaccinatum Recent history of smallpox vaccination or contact with an individual who received vaccination recently Papules, vesicles, umbilicated pustules, or erosions at the site of active dermatitis or previous eczema lesions Lesions might be distant from the inoculation Other symptoms include fever, malaise, and lymphadenopathy Eczema vaccinatum is fatal when it leads to supraepiglottic edema 2 , 5 Impetigo Highly contagious superficial skin infection that mostly affects children aged 2 to 5 y Staphylococcus aureus is the most important causative organism Lesion manifests as a single red papule or macule that quickly becomes a vesicle and an erosion.
Subsequently, the content dries, forming honey-coloured crusts Infection commonly resolves spontaneously 8 Primary varicella infection Primary varicella infection, also known as chickenpox, is caused by the varicella-zoster virus Initial exanthema consists of disseminated pruritic erythematous macules that progress beyond the papular stage, forming clear, fluid-filled vesicles like dewdrops on a rose petal 1.
Conclusion Atopic dermatitis is the most common diagnosis in the outpatient department for pediatric dermatology. Footnotes Competing interests None declared. References 1. Nelson textbook of pediatrics. Philadelphia, PA: Saunders Elsevier; Treadwell PA. Eczema and infection. Pediatr Infect Dis J. Consensus conference on pediatric atopic dermatitis. J Am Acad Dermatol. Viral infections in atopic dermatitis: pathogenic aspects and clinical management. J Allergy Clin Immunol.
Jen M, Chang MW. Eczema herpeticum and eczema vaccinatum in children. Pediatr Ann. Eczema herpeticum: making the diagnosis in the emergency department. J Emerg Med. Cole C, Gazewood J.
Dermatitis herpetiformis DH is a chronic autoimmune blistering skin condition,  characterised by blisters filled with a watery fluid  that is intensely itchy. DH is a cutaneous manifestation of Coeliac disease. Dermatitis herpetiformis was first described by Louis Adolphus Duhring in The age of onset is usually about 15—40, but DH also may affect children and the elderly. Men are slightly more affected than women.
What's to know about eczema herpeticum?
When the skin of someone with eczema comes into contact with the herpes virus, they may develop eczema herpeticum. A rare and sometimes serious condition, eczema herpeticum causes symptoms that can lead to a medical emergency. This article gives an overview of both eczema and herpes. It goes on to explore the causes, symptoms, and treatments for eczema herpeticum, the infection that happens when these two conditions meet. Herpes does not cause serious health problems for someone with a healthy immune system. Eczema herpeticum is a rare but serious complication, which can happen when skin that is affected by eczema comes into contact with the herpes virus. It is most often caused by contact with a cold sore HSV-1 and usually occurs on the:.