Eczema Herpeticum · What Is It, Causes, Diagnosis, and More

Eczema herpeticum is a skin infection caused by herpes simplex virus (HSV) 1 or 2 in individuals who have atopic dermatitis (i.e., eczema), an inflammatory skin condition characterized 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 vesicles and pustules (i.e., fluid-filled bumps of the skin) with hemorrhagic crust. The vesicles appear widely over the body but are most common on the face, neck, and trunk. Older lesions that have burst and dried commonly form “punched-out” erosions, which are circular breaks in the skin with sharply defined borders.   

Some individuals develop additional symptoms, like fever, swollen lymph nodes (i.e., lymphadenopathy), and cold sores (i.e., vesicles around the lips), while others with the infection are asymptomatic. Frequently, the skin lesions of eczema herpeticum become infected with bacteria, commonly Staphylococcus aureus and Streptococcus pyogenes, causing a secondary bacterial infection. In such cases, impetiginization (i.e., honey-colored crusting) and increased redness, swelling, and pain may occur. Eczema herpeticum most often affects infants and children, but people of all ages can develop this infection. 

Direct contact with the HSV is the most common cause of eczema herpeticum. HSV is categorized into two 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 (e.g., physical or chemical injury to the skin); Hailey-Hailey disease; and Darier disease, both rare genetic disorders. Hailey-Hailey disease typically presents with eroded vesicles and blisters in the folds of the skin (e.g., armpits, groin), while Darier disease generally causes dry, scaly papules (i.e., small, raised bump) on the chest and face. 

In healthy adults eczema herpeticum is typically self-limited, lasting 2-4 weeks, and treatment can shorten the course. However, in children and young infants treatment should be initiated 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. Cool compresses and lotions can be used for symptomatic relief of itching and pain. 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 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. 

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.