Eczema herpeticum

Question 1

A 3 year old girl with known eczema is brought to your general practice due to increasing symptoms despite regular treatment. She frequently gets an erythematous, dry, pruritic rash in her limb flexures, on her wrists and cheeks which normally responds to treatment. On this occasion, the lesions on her right cheek are not responding like previously. It has become painful and itchy with numerous vesicles. Some of these vesicles have ruptured leaving “punched out” lesions. She is currently afebrile. The family are planning of visiting her Aunty and newborn sousing tomorrow.

Answer 1

Impression
Given the known Eczema, with the new clinical symptoms with punched out facial lesions, pain and itch. In this case, I am concerned about a superimposed HSV infection (1/2 but likely 1).

HSV can spread rapidly, leading to severe morbidity and mortality in the absence of appropriate antiviral treatment.

DDx
- other infective: impetigo, bullous impetigo, varicella, hand-foot-mouth (coxsackium), varicella zoster, Dermatitis herpetiformis (assoc w coeliac disease), parvovirus, molluscum, cellulitus, pomfliix eczema, varicella
- eczema flare? (unlikely to give vesicles)

Main concerns
- thorough assessment
- management of HSV infection with antivirals
- recommend not visiting family to limit spread given contagious viral infection, staying home to prevent spread esp for pregnant and immunocompromised people.

Question 2

Eczema herpeticum - History

Answer 2

History
- sx: infective sx (fevers, malaise, arthralgia, myalgia), description of rash, time-course and when started, pain (SOCRATES)
- other manifestations: pharynx, ear, ocular, brain (severe),
- ask about eczema, treatments provided, how long had it, severity,
- medications (immunosuppressants), immunisations
- paeds hx

Question 3

Eczema herpeticum - Examination

Answer 3

Examination
- general inspection + vitals:
- Skin: scaly lesions in skin folds, lesions on face - clustered vesicles on erythematous base, punched out erosions, examine distribution (following cranial nerve), any ooze/excretions/pus?
- systems review for any signs of systemic illness

Question 4

Eczema herpeticum - investigations

Answer 4

Investigations
- Is a clinical diagnosis, no investigations required.
- Could confirm with swab of vesicular lesions for PCR and culture - altho start treatment before results return if suspicious of HSV infection

Question 5

Eczema herpeticum - Management

Answer 5

Management
- clinical diagnosis, mx on outpatient basis
- parent education
- referral to ophthalmology/derm depending on severity and distribution

Eczema
- ask about current treatment
- escalate/optimise management
o (if Dry) Moisturiser up to 4x daily
o Steroid (Advantan) + moisturiser (if red and dry), if using then ensure steroid before moisturiser, put emollient over the top to stop it washing off
o Avoid triggers
o Treat concomitant infections (oral antibiotics, topical ABx)
o Use Elidel (tacrolimus cream) if its on the face
o NO food or animal based products on skin - leads to allergy
o bathing: bleach baths, daily baths (reduces bacteria on skin and good for reducing infections)
o Wet dressings

HSV infection
- PO antiviral medication (aciclovir) 5x daily for 7 days, ONLY give if rash has been there for less than 72 hours
- impetigo mx for lesions: soak in warm water, remove any crusted lesions gently
- if bacterial: topical mucopuricin BD for 5 days, could then escalate to clarithromycin