December 2006

This is a 3.5-year-old girl with a history of atopic dermatitis who presented to the children’s hospital emergency department with fever and weeping erosions overlying erythematous skin. The erosions were especially noticeable around the mouth, the thigh, and the flexural areas of the arms and legs. She was seen earlier in the week at a local emergency department and treated with oral prednisone, antibiotics, and whirlpool therapy. What is your diagnosis?

Answer

The girl has eczema herpeticum.

Eczema herpeticum is a subset of Kaposi’s varicelliform eruption. Other presentations are seen in patients after smallpox vaccination. Eczema is by far the most common underlying skin disorder associated with this condition. Our patient had significant and poorly controlled atopic dermatitis. Her mother revealed that one week prior to presentation, she had slept with her sister who had herpes labialis.

Although the exact etiology of eczema herpeticum is unknown, epidermal barrier disruption is thought to be a major contributing factor. Thus, the disease has also been described in other barrier defects such as Darier’s disease, psoriasis, lupus erythematosus, burns and after dermabrasion. Some studies have suggested that underlying immune abnormalities that occur in atopic dermatitis may also play a role. These include the possibility of a decreased number of circulating natural killer cells, as well as a depressed cell-mediated immunity in general.

Patients usually present with a sudden onset of widespread outbreak of vesicles and erosions in areas of active dermatitis, especially on the face and neck. This condition is often accompanied by fever and malaise, and the eruption is usually painful. Treatment includes systemic antiviral therapy, maintenance of hydration, pain control and treatment of any secondary bacterial infection.

The cutaneous eruption should be treated with generous application of bland emollients. Topical anti-inflammatory agents should be added once the viral outbreak is healing. If the area around the eyes is involved, consultation with an ophthalmologist is mandated to monitor for the development of herpetic keratitis.

For more information:

• Kramer SC, et al: Kaposi’s varicelliform eruption: a case report and review of the literature. Cutis. 2004; 73:115-122.
• Paller AS and Mancini AJ, eds. Hurwitz Clinical Pediatric Dermatology. Philadelphia: Elsevier Saunders; 2006.
• Wollenberg A, et al: Viral infections in atopic dermatitis: pathogenic aspects and clinical management. J Allergy Immunol. 2003:112:667-674.