An Approach to Eczema Herpeticum
A 20-year-old female with a history of eczema and asthma presents with an exacerbation of her underlying eczema, associated with severe pain. She states that this episode has been getting worse over the past 5 days.
She notes that 5 days ago she had a laser treatment therapy which she has every several weeks. They had to stop and do a shorter session because the patient had worsening of the rash. The mother states that it was very bad 5 days ago and has been getting worse.
The patient states that the pain is moderate to severe, all over her upper arms and worse in her armpits. It is burning in nature. She notes some bruising. She has been trying topical mupirocin. She was advised by her private dermatologist to not use steroids if she presents to the emergency department.
Patient denies fever, chills, nausea, and vomiting. She denies overt sloughing of the skin but states that she has dry skin all over her clothes. There have been no blisters or bullae. She points out that it is mild on her stomach, back, posterior popliteal fossa as well. She states that there is no mucous membrane involvement in her mouth, eyes, or vagina.
General: Patient is very obviously uncomfortable and in pain. Nontoxic.
Weepy erythematous and excoriated patches diffusely across bilateral arms; there is prominent honey colored crust. Tender diffusely.
Macerated and weepy plaques bilateral axillae and diffusely across neck
Faint erythematous, sclerotic patches peri-orbitally bilaterally
Excoriated, erythematous patches bilateral popliteal fossae
Pink diffuse eczematous patches on abdomen
DDx: eczema herpeticum (see images here)
ED Workup/Management: Labs, IVFs, oxycodone, dermatology consult, wound swabs
Final Dx: atopic dermatitis, flaring complicated by impetiginized atopic dermatitis
Keflex 500 mg TID
Hydrocortisone 2.5% ointment BID for up to 2 weeks of eyelids, neck and axillae (please specify on prescription that formulation should not contain propylene glycol)
Triamcinolone 0.1% ointment BID for up to 2 weeks for extremities/trunk; do not apply to above listed locations (please specify on prescription that formulation should not contain propylene glycol)
Atarax 10 mg every night PRN itching; can increase by 10 mg nightly to maximum dose of 30 mg as tolerated
Xyzal 5 mg every morning PRN itching, discontinue all other topicals including soaps and trial Vanicream products
Dermatology follow up this week
Follow-Up Culture: MSSA +, HSV
Take Away #1
As it is life-threatening and requires hospitalization, eczema herpeticum must be considered in patients with a history of atopic dermatitis presenting with painful eczema flare.
Take Away #2
Complications of eczema herpeticum can lead to disseminated HSV (keratoconjunctivitis - potentially sight-threatening, meningitis, encephalitis) or superimposed bacterial infection leading to sepsis. Treatment must cover Staph, Strep, and HSV. If you have high clinical suspicion, obviously admit these patients.
Take Away #3
Eczema herpeticum is one of the few differentials that dermatology will come in for so get them involved early!
Ryan Barnicle, MD, M.Ed is a current third year resident at Stony Brook Emergency Medicine. He can be reached on Twitter @ryan_barnicle.
Additional Case Reports
Micali, Giuseppe, and Francesco Lacarrubba. 2017. “Eczema Herpeticum.” The New England Journal of Medicine 377 (7): e9.
Edited by Bassam Zahid, MD