2. HISTORY
11 year old boy
Known eczema since age of 3
Presented with 1 day history of:
Sudden onset tender vesicular lesions on right side of
face and neck. Burning sensation on face
Redness on the right eye with some discharge
Headache and vomiting 3-4x 1/7 ago but not on the day
of admission
No fever or vomiting
PMH:?infected eczema in the past. Discharged
from clinic in April.
DH: epiderm BD & eumovate TDS
4. EXAMINATION
Obs stable (T: 37.1, P 101)
Alert, well-hydrated, not in distress
Eczematous rash on face, neck, elbows, hands and
left ankle
Pustular, vesicular eruption in clusters over right
side of face, neck and behind left ear. No lesion in
the ear
Right eye – swollen lid margins, red conjunctive,
purulent discharge. No pain, normal eye
movements and reactive to light
Otherwise normal
6. MANAGEMENT
Admitted to ward
Start IV aciclovir, Benzylpenicillin and Flucloxacillin
Routine bloods + Herpes PCR
Skin swab and eye swab for bacteriology and
virology
Chloramphenicol eye ointment (d/w opthal reg)
Referral to opthalmology and dermatology
7. DERMATOLOGY REVIEW
Continue IV treatment for 1 week
Doublebase emollient
Paste bandages (viscopaste)
Betnovate QC ointment to limb under viscopaste
bandages
Chloramphenicol cream to face
Vioform HC to face – not available, hydrocortisone
0.5% cream prescribed
8. RESULTS
Swabs – staphylococcus aureus
Blood culture –ve
Routine bloods normal
PCR – HSV DNA type 1/2 not detected
9. DISCHARGE
Discharge with dermatology follow up in one week
Oral aciclovir five times/day (total 10 days)
Oral flucloxacillin 1g QDS (total 7 day)
Phenoxymethylpenicillin 500mg QDS (total 7 days)
Chloramphenicol eye drops QDS for 1 week
Doublebase gel
Hydrocortisone 1% cream BD
Betamethasone valerate 0.1% ointment under
viscopaste bandages in the morning
10. ECZEMA HERPETICUM
Acute disseminated herpes simplex infection, often
associated with systemic symptoms, in patients
with atopic dermatitis
Commonly involve HSV type 1 or type 2
Rarely vaccinia virus and Coxsackie A16 virus
Infection may be from auto-innoculation or from
infected contact
11. CLINICAL PRESENTATION
Multiple clusters of vesicles in areas of pre-existing
atopic dermatitis
Spreading (to normal skin), haemorrhagic and
crusted
Painful punched out erosions, which may coalesce
to form larger areas of erosions and crusting
Majority of patients have fever and malaise
Subclinical herpetic infection is quite common
15. IMPETIGO VS ECZEMA HERPETICUM
Features that favour impetigo
Honey-coloured crust
Slower evolution
Fewer systemic symptoms
Features that favour eczema
Punched out erosions
16. INVESTIGATION
Swab for virology (PCR) and bacteriology from
fresh vesicle
Other investigations:
Bloods: FBC, biochem (CRP & albumin)
Other tests to diagnose viral infection:
Tzanck preparation
Direct fluorescent antibody testing
17. MANAGEMENT
Consider advising patient to discard previously used
emmolient (esp if it is stored in tubs) or creams if
contamination is suspected
Initiate treatment on the same day (delay may increase
length of hospital stay)
IV or oral aciclovir
IV or oral antibiotics (flucloxacillin & benzylpenicillin) for
secondary bacterial infection
Topical antibiotics cream if no evidence of bacterial infection
(rarely used in UK due to bacterial resistance)
Topical opthalmic antiviral may be added if there is evidence
of periocular involvement (keratitis prophylaxis)
Dermatology referral
Opthalmology referral for periocular lesions
18. MANAGEMENT OF ECZEMA
Steroids from least to most potent:
Hydrocortisone, eumovate (clobetasone), betnovate (betamethasone),
dermovate (clobetasol)
Topical calcineurin inhibitor (tacrolimus) may be used on face if
hydrocortisone is not sufficient. The use of stronger steroids is not
recommended on face
Side effect of steroids: skin thinning, telangiectasia, adrenal suppression
19. PROGNOSIS
Very low mortality with the availability of effective
antivirals
Average duration of illness is 16 days, cases lasting
as long as 6 weeks have been reported.
Recurrent episodes tend to be milder and are not
associated with systemic symptoms.
Complications if untreated:
Herpes hepatitis
DIC
Herpes keratitis, conjunctivitis
In disseminated infection can involve brain, lung, GI and
adrenal
20. CONCLUSION
Although potentially life threatening, if eczema
herpeticum is recognized early it is easily and
effectively treated.
Any patient with history of atopic dermatitis and
acute "blistering" should be examined for eczema
herpeticum.
21. REFERENCES
Royal college of paediatrics and child health allergy care
pathways for children eczema
Aronson PL, Yan AC, Mittal MK, Mohamad Z, Shah
SS Delayed acyclovir and outcomes of children hospitalized
with eczema herpeticum. [Journal Article, Multicenter Study,
Research Support, N.I.H., Extramural, Research Support,
Non-U.S. Gov't]
Pediatrics 2011 Dec; 128(6):1161-7.
Brook, I., Frazier, E.H., & Yeager, J.K. (1998). Microbiology of
infected eczema herpeticum. Journal of the Academy of
Dermatology, 38, 627-629.
Sais, G., Jucgla, A., Curco, N., & Peyri, J. (1994). Kaposi's
varicelliform eruption with ocular involvement. Archives of
Dermatology, 130, 1209-1210
CG57 Atopic eczema in children: NICE guideline
Mooney MA, Janniger CK, Schwartz RA. Kaposi's
varicelliform eruption. Cutis. 1994;53:243-245.
Notes de l'éditeur
The type most commonly used is called PB7 or Viscopaste. This bandage is covered in a thick white zinc paste which acts as a moisturiser. The main benefits of these bandages is to moisturise the skin and save the skin from further damage from scratching, as well as allowing the skin to heal from previous scratching. These bandages are also very useful on the arms and legs for areas of eczema, which have become much thickened from scratching over a period of time. They cool and soothe the skin and can help to break the cycle of itching and scratching.
Patients often contract the virus by direct contact with an infected person (eg, a kiss from a parent with herpes labialis).5 Eczema herpeticum can also occur in the setting of a primary HSV infection.
Herpes simplex virus 1 — which usually causes herpes labialis or “cold sores,” and herpes simplex virus 2 — which usually causes genital herpes, can be transferred to the skin by direct contact from the patient or from another infected individual. Rarely, other viruses can cause EH and include vaccinia virus and Coxsackie A16 virus.
Royal college of paediatrics and child health allergy care pathways for children eczemaCulture takes at least 48 hours for final results and may be negative if a swab is taken from a crusted site, often seen in older lesionshe quickest method of diagnosis is the time-honoredTzanck preparation. A #15 surgical blade should be used to open the top of a vesicle, scraping the underside of the vesicle as well as the base. The blade is then wiped across a glass slide, heat-fixed, and stained with toluidine blue. A positive prep reveals multinucleated giant cells with molded, jigsaw-puzzle nuclei in addition to acantholytic balloon cells (Mooney et al., 1994) (see Figure 4) A positive prep will confirm viral infection, but is not virus-specificDirect fluorescent antibody testing enables rapid identification of the virus. A slide is prepared as above but is not stained. It is sent to the laboratory for immunofluorescent examination with antibodies against HSV-1 and HSV-2 (Braun-Falco et al., 2000). Results are available within several hours.
delay of acyclovir initiation by 1 day was associated with an 11% increased LOS (95% confidence interval [CI]: 3%-20%; P = .008), and LOS increased by 41% when acyclovir was started on day 3 (95% CI: 19%-67%; P < .001) and by 98% when started on day 4 to 7 (95% CI: 60%-145%; P < .001). Use of topical corticosteroids on day 1 of hospitalization was not associated with LOS.Delay of acyclovir initiation is associated with increased LOS in hospitalized children with eczema herpeticum. Use of topical corticosteroids on admission is not associated with increased LOS. The mortality rate of hospitalized children with eczema herpeticum is low. Aronson PL, Yan AC, Mittal MK, Mohamad Z, Shah SS Delayed acyclovir and outcomes of children hospitalized with eczema herpeticum. [Journal Article, Multicenter Study, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't]Pediatrics 2011 Dec; 128(6):1161-7.Patients on IV acyclovir require adequate fluid intake and monitoring to prevent acute renal failure due to crystalline nephropathy. Eczema herpeticum is usually managed on an outpatient basis. Inpatient treatment is reserved for patients with more severe cases (eg, high fever, poor oral intake, evidence of secondary infection). Acyclovir remains the most studied and frequently used treatment. The pyrophosphate analogfoscarnet is also effective and may be used in the rare case of acyclovir-resistant herpes.1When eczema herpeticum involves the skin around the eye, a topical ophthalmic antiviral may be added for keratitis prophylaxis. For the treatment of bacterial superinfection, an oral cephalosporin and topical antiseptic lotion may be adequate. Treatment with topical or systemic corticosteroids is still controversial: most clinicians avoid it
