Eczema Herpeticum

Get CMEEczema HerpeticumThe evaluation of pediatric patients with rashes is a common occurrence in the Ped ED… and a common area of frustration for many of us (ok, maybe it is just me).  We have previously covered an approach to the evaluation of the Pediatric Rash.  We have also covered a variety of common causes of pediatric rashes (ex, Scabies, Tinea, Diaper Dermatitis and Molluscum) including eczema. While many of these conditions are simple nuisances, some can become more problematic. Let’s make sure we stay vigilant for Eczema Herpeticum.


Eczema Herpeticum: Basics

  • Atopic dermatitis is an inflammatory skin disease
  • The inflammatory states creates an impaired skin barrier
  • The impaired protection increases risk for bacterial and viral infections
  • Eczema herpeticum
    • HSV skin infection that occurs in patients with atopic dermatitis.
    • Occurs in 3-6% of patients with atopic dermatitis.
    • Can be due to HSV1 or HSV2, but also other viruses can cause it (ex, varicella, poxvirus)
    • May occur with either primary or recurrent HSV infection. [Wollenberg, 2003]
    • More likely to occur in those patients with:
      • Extensive eczema skin involvement
      • Early onset of eczema [Wollenberg, 2003]
      • Eczema lesions on head and neck
      • High IgE levels
    • Children who are young (1 year or younger) or have systemic illness (ex, fever) are more likely to require hospitalization. [Luca, 2012]
    • Fortunately, overall mortality is low. [Aronson, 2013; Aronson, 2011]


Eczema Herpeticum: Presentation

  • Systemic symptoms
    • Fever
    • Malaise
    • Lymphadenopathy
  • Skin eruption
    • Monomorphic eruption of dome-shaped vesicles 
      • Initially starts in region of eczema
      • Can spread to involve normal skin also
    • Lesions may crust and form superficial pits and erosions
    • Head, neck, and trunk frequently affected.
      • Lesions can affect the eye and cause keratoconjunctivitis.
    • Fluid from vesicles can be sent for HSV PCR or viral culture to confirm diagnosis.
  • May have bacterial infection superinfection 
    • S. aureus is commonly cultured (~30%). [Aronson, 2011]
    • Septicemia cases can occur, but less commonly (~3%).  [Aronson, 2011]
  • Dissemination of HSV
    • Multiple organ involvement
    • DIC
    • Meningitis/encephalitis


Eczema Herpeticum: Treatment

  • Acyclovir is the traditional therapy
    • Depending on severity of condition, oral or IV is appropriate
    • Oral acyclovir has low bioavailability, so only use for mild cases.
  • Delayed administration of acyclovir in hospitalized patients is associated with increased length of stay. [Aronson, 2011]
    • Each day of delayed initiation of acyclovir increased LOS.
    • Challenging to recognize, but important to consider and initiate therapy early, similar to neonatal HSV.
  • Steroids
    • Topical steroids
      • Concern that topical steroids may increase spread of HSV infection.
      • Topical steroids are not definitively associated with worsening disease and prolonged LOS.  [Aronson, 2013; Aronson, 2011]
      • May be prudent to wait until acyclovir has been initiated.  [Aronson, 2011]
    • Systemic steroids do worsen eczema herpeticum and increase LOS.  [Aronson, 2013; Aronson, 2011]
  • Antibiotics
    • Empiric antibiotics for all kids have not shown to improve outcomes. [Aronson, 2013]
    • Early recognition of serious bacterial infection is important, however.


Moral of the Morsel

  • Most rashes in children are benign, but remain vigilant.
  • Eczema injures one of the body’s primary defenses against the outside world, so always consider bacterial as well as viral super-infections.
  • If you see blisters in child with eczema, think Eczema Herpeticum!
  • Obtain HSV PCR and viral culture of fluid from blisters and initiate acyclovir.



Blanter M1, Vickers J, Russo M, Safai B. Eczema Herpeticum: Would You Know It If You Saw It? Pediatr Emerg Care. 2015 Aug;31(8):586-8. PMID: 26241712. [PubMed] [Read by QxMD]

Aronson PL1, Shah SS, Mohamad Z, Yan AC. Topical corticosteroids and hospital length of stay in children with eczema herpeticum. Pediatr Dermatol. 2013 Mar-Apr;30(2):215-21. PMID: 23039248. [PubMed] [Read by QxMD]

Aronson PL1, Yan AC, Mohamad Z, Mittal MK, Shah SS. Empiric antibiotics and outcomes of children hospitalized with eczema herpeticum. Pediatr Dermatol. 2013 Mar-Apr;30(2):207-14. PMID: 22994962. [PubMed] [Read by QxMD]

Luca NJ1, Lara-Corrales I, Pope E. Eczema herpeticum in children: clinical features and factors predictive of hospitalization. J Pediatr. 2012 Oct;161(4):671-5. PMID: 22575249. [PubMed] [Read by QxMD]

Aronson PL1, Yan AC, Mittal MK, Mohamad Z, Shah SS. Delayed acyclovir and outcomes of children hospitalized with eczema herpeticum. Pediatrics. 2011 Dec;128(6):1161-7. PMID: 22084327. [PubMed] [Read by QxMD]

Wollenberg A1, Zoch C, Wetzel S, Plewig G, Przybilla B. Predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of 100 cases. J Am Acad Dermatol. 2003 Aug;49(2):198-205. PMID: 12894065. [PubMed] [Read by QxMD]

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. I am looking at this article because my son is having a repeat episode. I just wanted to point out that he did not have any blisters as you would assume for a classic case. They were mostly just spots that sort of scabbed over with very dark black tops. That eventually came off. Any advice for stopping repeat episodes? He refuses to take valtrex because he is 4 and the crushed up pills are so bad tasting.

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