Eczema herpeticum: A medical emergency in patients with atopic dermatitis

Abstract

We describe the case of a 13-year-old girl with atopic dermatitis (AD) and severe asthma that presented to the Dermatology clinic with a pruritic skin rash, which appeared concomitantly to common cold symptoms. On examination, there are erythematous, umbilicated papules and vesicles, some with erosions and crusting, surrounding the mouth and areolas; a few lesions are visible on the forearms. The mucous membranes were unaffected, the patient was afebrile, and no lymphadenopathies were present. A diagnosis of eczema herpeticum (HE) was suspected, and a direct fluorescent antibody test was positive for herpes simplex virus. Even when the clinical presentation is characteristic, the eruption might be confused with other infections like impetigo and primary varicella infection. Misdiagnosis can lead to severe complications, including bacteremia and death. EH is considered a medical emergency, and the index of suspicion for this infection should be high among clinicians. Prompt treatment with oral acyclovir should be initiated; in cases of severe disease or immunocompromised patients, hospitalization for systemic antivirals is required. If EH is recognized early it is easily and effectively treated. Any patient with pre-existing skin disease and acute "blistering" should be examined to rule out EH.

A 13-year-old girl with atopic dermatitis (AD) and severe asthma presented to the Dermatology clinic with a pruritic skin rash, which appeared concomitantly to common cold symptoms. On examination, there were erythematous, umbilicated papules and vesicles, some with erosions and crusting, surrounding the mouth (Panel 1), areolas (Panel 2), and a few lesions are visible on the forearms (Panel 3). The mucous membranes were unaffected, the patient was afebrile, and no lymphadenopathies were present. A diagnosis of eczema herpeticum (HE) was suspected, and a direct fluorescent antibody test was positive for herpes simplex virus-1.

Panel 1.

Erythematous, umbilicated papules and vesicles, some with erosions and crusting around the mouth.

Panel 2.

Erythematous, umbilicated papules and vesicles, some with erosions and crusting, surrounding the areolas.

Panel 3.

Few erythematous, umbilicated papules and vesicles on the forearms.

EH occurs on areas of preexisting skin disease and is usually caused by herpes simplex virus. It presents as small, dome-shaped, grouped papule-vesicles on an erythematous base that rupture leaving punched-out ulcers, most often on the face, neck, and upper trunk; the typical presentation might be challenging to recognize in patients with severe or poorly controlled AD. Systemic symptoms such as fever, malaise, and lymphadenopathies may be present.

Even when the clinical presentation is characteristic, the eruption might be confused with other infections like impetigo and primary varicella infection. Misdiagnosis can lead to severe complications, including bacteremia and death. EH is considered a medical emergency, and the index of suspicion for this infection should be high among clinicians. Prompt treatment with oral acyclovir should be initiated; in cases of severe disease or immunocompromised patients, hospitalization for systemic antivirals is required.

Prompt treatment with oral acyclovir should be initiated; in cases of severe disease or immunocompromised patients, hospitalization for systemic antivirals is required.

It is important to remember that children with AD are at highest risk for developing EH, so this potentially dangerous diagnosis should be considered in any AD patient presenting with an acute pruritic rash.

Any patient with pre-existing skin disease and acute "blistering" should be examined to rule out EH.