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Eczema Herpeticum

What Is It, Causes, Diagnosis, and More

Author: Nikol Natalia Armata

Editors: Alyssa Haag, Kelsey LaFayette, BAN, RN

Illustrator: Jillian Dunbar

Copyeditor: Joy Mapes


What is eczema herpeticum?

Eczema herpeticum is a skin infection caused by the herpes simplex virus (HSV). It most commonly develops in individuals who already have atopic dermatitis (i.e., eczema), an inflammatory skin condition characterised by skin dryness and itching. Individuals with atopic dermatitis are more prone to developing viral skin infections, such as eczema herpeticum, due to reduced immunity and their skin’s impaired ability to form a barrier against infections.

The skin lesions of eczema herpeticum typically present as painful clusters of blisters, fluid-filled elevations of the skin. The blisters appear widely over the body but are most common on the face, neck, and trunk. Older blisters that have burst and dried commonly form “punched out” erosions, which are circular breaks in the continuity of the skin that may bleed or produce pus.

Some infected individuals develop additional symptoms, like fever, swollen lymph nodes (i.e., lymphadenopathy), and cold sores (i.e., blisters around the lips), while others with the infection are asymptomatic, or without symptoms. Frequently, the skin lesions of eczema herpeticum become infected with bacteria, commonly staphylococci or streptococci, causing what is known as a secondary bacterial infection. In such cases, additional symptoms -- such as increased redness, swelling, and pain -- may occur.

Eczema herpeticum most often affects infants and children, but people of all ages can develop this infection. 

What causes eczema herpeticum?

Direct contact with the herpes simplex virus (HSV) is the most common cause of eczema herpeticum. HSV is categorized into 2 types: type 1 and type 2. Type 1 is highly contagious and is the leading cause of eczema herpeticum. Often, eczema herpeticum presents 5 to 12 days after the first contact with herpes simplex.

Non-eczematous conditions that disrupt the continuity of the skin are also considered risk factors for eczema herpeticum, as they can increase an individual’s susceptibility to localized herpes infections. Such skin conditions include burns; irritant contact dermatitis, which occurs  when friction, environmental changes, or exposure to chemicals damage the skin; Hailey-Hailey disease; and Darier disease. 

Hailey-Hailey disease and Darier disease are both rare genetic disorders. Hailey-Hailey disease typically presents with blisters and erosions near folds of the skin (e.g., armpits, groin), while Darier disease generally causes dry, crusted papules, or small elevations of the skin, to form under the breasts or on the neck. 

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Is eczema herpeticum contagious?

Eczema herpeticum is a contagious infection that can spread through direct skin-to-skin contact with an infected individual, even if the infected individual does not have a current outbreak. Infected individuals are also able to infect other parts of their body through what is called “self-infection,” or autoinoculation. 

How is eczema herpeticum diagnosed and treated?

Eczema herpeticum is often diagnosed clinically based on the individual's history (e.g., of atopic dermatitis) and the characteristic appearance of the skin lesions. Diagnosis can be confirmed via viral swabs taken from the base of fresh blisters, which are typically analyzed through viral culture or polymerase chain reaction (PCR). A Tzanck smear, a diagnostic method that can rapidly detect a herpes simplex infection, can also be used to confirm diagnosis of eczema herpeticum and rule out other potential diagnoses. Other viruses and bacteria can cause similar-appearing skin lesions, so careful examination and proper diagnostic testing of the individual is necessary to obtain an accurate diagnosis.

Treatment for eczema herpeticum should begin as soon as possible. Oral antiviral medication, such as acyclovir or valacyclovir, is often prescribed to minimize the risk of complications and prevent progression to severe disease.

Additional treatment will depend on the severity of the lesions. Most mild cases can be treated with oral antiviral medication for a range of 7-21 days. In more severe cases -- specifically when the individual’s immune system is weakened due to another condition (e.g., HIV, prolonged diabetes, leukemia, undernutrition) or certain treatments (e.g., corticosteroids and other immunosuppressant medications, chemotherapy, radiation therapy) -- hospitalization should be considered for intravenous (IV) administration of the antiviral medication and supportive care of other symptoms. Critically ill individuals may also need additional fluids, pain relievers, and wound care to assist with healing. Furthermore, individuals should be monitored for the development of secondary bacterial infection, and if infection occurs, they will most likely need treatment with systemic antibiotics.

In order to prevent spread of the infection, all individuals with eczema herpteticum should be educated about self-infection. Contact precautions, such as wearing gloves and frequently washing hands, are often recommended when herpes simplex infections are suspected. 

What are the most important facts to know about eczema herpeticum?

Eczema herpeticum is a skin infection of herpes simplex virus (HSV) that commonly develops in patients with atopic dermatitis. It is more common in children, where it presents with painful blisters and “punched out” erosions. Eczema herpeticum is caused by the herpes simplex virus, especially type 1 (HSV-1). Risk factors include pre-existing atopic dermatitis and other non-eczematous skin conditions that disrupt the continuity of the skin. Eczema herpeticum is highly contagious among both symptomatic and asymptomatic individuals. Therefore, prompt and proper diagnosis is important and should be based on clinical presentation and, if necessary, viral swabs. Treatment typically involves antiviral medication, administered in doses that depend on the severity of the case. In cases of secondary bacterial infection, antibiotics may also be prescribed. 

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Related links

Atopic dermatitis
Herpes simplex virus
Eczematous rashes
Blistering skin disorders
Herpesvirus medications

Resources for research and reference

Fernandez, J. (2021). Overview of immunodeficiency disorders. In Merck Manual: Consumer Version. Retrieved May 27, 2021, from https://www.merckmanuals.com/home/immune-disorders/immunodeficiency-disorders/overview-of-immunodeficiency-disorders 

Lin, C.-Y. (2010). Eczema herpeticum. In DermNet NZ: Topics A-Z. Retrieved March 10, 2021, from https://dermnetnz.org/topics/eczema-herpeticum/ 

National Organization for Rare Disorders (NORD). (2018). Hailey-Hailey disease. In Rare Disease Database. Retrieved March 30, 2021, from https://rarediseases.org/rare-diseases/hailey-hailey-disease/ 

Stanway, A., & Oakley, A. (2016). Darier disease. In DermNet NZ: Topics A-Z. Retrieved March 30, 2021, from https://dermnetnz.org/topics/darier-disease/ 

Xiao, A., & Tsuchiya, A. (2020, September 27). Eczema herpeticum. In StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560781/