Eczema Coxsackium

Sir,

A 3-year-old boy was referred to the Dermatology outpatient section from the department of Pediatrics with a history of fever and skin lesions over the hands, feet, and abdomen for 3 days. On examination, there were multiple elongated vesicles with surrounding erythema over the palms, palmar aspect of the digits [Figure 1], soles [Figure 2], and knees. Few erythematous erosions were seen on the hard palate. In addition, numerous crusted papules, some of them confluent, with few vesicles and surrounding erythema and maceration were found in the groins, abdominal folds, and scrotum [Figure 3]. On being asked specifically, the mother gave a history of redness and oozing in the groin and abdominal folds for 1 week. She also said that fluid-filled lesions appeared over those areas first, followed by the palms and soles. Based on the history and examination findings, the child was diagnosed with hand foot and mouth disease (HFMD) with eczema coxsackium over preexisting intertrigo. Laboratory confirmation of the diagnosis by culture in cell lines such as human rhabdomyosarcoma cells, IgM enzyme-linked immunosorbent assay, or reverse transcriptase-polymerase chain reaction could not be done due to lack of facilities. As the lesions were resolving, he was given symptomatic treatment with calamine lotion and antihistamines.

Figure 1.

Elongated papulovesicles over palm and palmar aspect of fingers

Figure 2.

Erythematous papulovesicles over sole

Figure 3.

Crusted papules, vesicles and surrounding erythema and maceration in the groins, abdominal folds, and scrotum

HFMD is caused commonly by coxsackievirus A16 (CVA16) and human enterovirus 71 (HEV71). Rarely, HFMD can be caused by CVA4–A7, A9, A10, B1-B3, and B5.[1] HFMD is a self-limiting illness characterized by mild fever followed by oval papulovesicular eruptions over hand, feet, perioral area, knees, buttocks, and oral cavity with perilesional erythema.[1] Outbreaks of HFMD has been described from different parts of India.[1] Eczema coxsackium was described as an unusual cutaneous manifestation of HFMD characterized by vesicles and erosions in areas affected by atopic dermatitis, similar to eczema herpeticum caused by herpes simplex virus 1.[2] This term was described during a CVA6–associated North American enterovirus outbreak of 2011–2012.[2] Apart from CVA6, CVA16 has also been isolated from the cases of eczema coxsackium.[2] Apart from atopic dermatitis, eczema coxsackium has been described in children with Darier's disease, epidermolytic ichthyosis, and a human immunodeficiency virus-infected adult patient.[2,3,4] Low-potency topical corticosteroid and wet wrap therapy have been used successfully to treat eczema coxsackium.[5]

As per the history given by the mother, our patient probably had preexisting intertrigo of the abdominal and groin folds, which resulted in early involvement and accentuation of vesicles in these areas. The morphology and clinical course of the disease were highly suggestive of eczema coxsackium. Awareness of this phenomenon is important for the accurate diagnosis of atypical manifestations of HFMD.

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