Eczema Herpeticum

Aka: Eczema Herpeticum, Kaposi Varicelliform Eruption

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II. Epidemiology

  1. Incidence
    1. Children in UK: 11 to 95 per 100,000 person years (UK data)
    2. Children in US: 40 to 78 per 100,000 (hospitalization rate)
  2. Age
    1. More common in children (immature Immune Systems)
  3. References
    1. Wan (2022) Br J Dermatol 186(4): 664-72 [PubMed]
    2. Hsu (2018) J Invest Dermatol 138(2): 265-72 [PubMed]

III. Pathophysiology

  1. Severe, disseminated Skin Infection with Herpes Simplex Virus (typically type 1)
  2. Infections are typically in patients with skin barrier defects (esp. Atopic Dermatitis, see risk factors below)
  3. Contributing factors
    1. Dysregulated immune response
    2. Altered skin flora
    3. Environmental exposures

IV. Risk Factors

  1. Younger children
  2. Atopic Dermatitis (esp. early onset, and under-treated)
  3. Seborrheic Dermatitis
  4. Burn Injury
  5. Post-operative complication (e.g. Cosmetic dermatology procedure)
  6. Inflammatory skin conditions

V. Symptoms

  1. Painful papulovesicular rash spread over localized skin region

VI. Signs

  1. Characteristics
    1. Disseminated non-grouped Vesicles on an erythematous base
    2. Vesicles progress to Pustules, then into erosions or punched out lesions after 2-7 days
    3. Crusts may overly lesions
    4. Lesion may require 2-6 weeks to resolve
  2. Distribution
    1. May affect any region with Atopic Dermatitis
    2. Head
    3. Face
    4. Neck
    5. Chest
  3. Severity
    1. Atopic Dermatitis severity correlates with Eczema Herpeticum severity
    2. Children are prone to more severe cases
  4. Associated findings
    1. Fever
    2. Malaise
    3. Lymphadenopathy
    4. Other systemic herpetic complications
      1. Herpes Simplex Keratitis (Keratoconjunctivitis)
        1. Corneal exam should include Fluorescein staining if periorbital infection is present
      2. Herpes Gingivostomatitis (may limit oral intake)
      3. HSV Encephalitis (Meningoencephalitis)
      4. Herpetic Whitlow

VII. Labs

  1. HSV PCR
    1. Do NOT delay treatment while awaiting results
  2. Other laboratory testing as indicated (e.g. septic workup with Blood Cultures)
    1. Basic chemistry panel including Renal Function (baseline and as needed, esp. with Acyclovir IV)
  3. Consider MRSA swabs (if superinfection suspected)

VIII. Differential Diagnosis

  1. See Vesicle
  2. Impetigo
  3. Eczematous Dermatitis
  4. Hand Foot and Mouth Disease
  5. Varicella Zoster Virus
  6. Herpes Gladiatorum
  7. Allergic Contact Dermatitis

IX. Complications

  1. Skin superinfections (e.g. MSSA or MRSA, Streptococcus Pyogenes)
  2. Herpes Simplex Keratitis
  3. Herpes Gingivostomatitis
  4. Systemic disease
    1. Viremia
    2. Bacteremia
    3. Death
      1. Mortality 0.1% with Antiviral management

X. Management

  1. Dermatologic emergency requiring prompt initiation of Antiviral therapy
    1. Consult dermatology
  2. Hospitalization
    1. Indications
      1. Management often starts with IV Antivirals (esp. children)
      2. Severe presentations
      3. Extensive disease involving the face, eye or Central Nervous System
    2. Management
      1. IV Acyclovir (and follow Renal Function)
        1. Transition to oral agents when able (see below)
      2. Treat superinfections (e.g. MSSA, MRSA)
      3. Intravenous Fluids as needed
  3. Outpatient Management
    1. Antivirals
      1. Acyclovir 20 mg/kg/dose (up to 800 mg) orally 5 times daily
      2. Valacyclovir 20 mg/kg/dose (up to 1000 mg) orally twice daily
    2. Treat superinfections (e.g. MSSA, MRSA) if present
      1. Cephalexin 50 mg/kg/day divided three times daily for 7 days
      2. Consider MRSA coverage
  4. Symptomatic management
    1. See Atopic Dermatitis for general measures
    2. Skin Emollients (e.g. petroleum jelly)
    3. Topical antibacterial as needed (e.g. Mupirocin)
    4. Medium potency Topical Corticosteroids may be considered (e.g. Triamcinolone cream)
      1. Topical Corticosteroids are safe in Eczema Herpeticum without worsening outcomes

XI. Course

  1. Lesions resolve with treatment over 2 to 6 weeks

XII. References

  1. Farnsworth (2026) Crit Dec Emerg Med 40(7): 17-8
  2. Laporte (2025) Crit Dec Emerg Med 39(12): 16-7

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