What is the treatment for eczema herpeticum?

Treatment of Eczema Herpeticum

Systemic antiviral therapy with acyclovir is the treatment of choice for eczema herpeticum. 1, 2

First-Line Treatment

• Systemic antiviral therapy:

  • Oral acyclovir is the standard first-line treatment 1, 3
  • Typical dosing: 200 mg five times daily for 5 days 4
  • For severe cases or immunocompromised patients, consider intravenous acyclovir

• Alternative antiviral options:

  • Valacyclovir (oral) can be used as an alternative with better bioavailability 5
  • Famciclovir is another potential alternative

Clinical Presentation and Diagnosis

• Eczema herpeticum presents as:

  • Sudden onset of monomorphic vesicles on areas affected by eczema
  • Often accompanied by fever, malaise, and systemic symptoms
  • Vesicles that evolve into painful erosions and punched-out lesions
  • Most commonly affects patients with atopic dermatitis

• Warning: Misdiagnosis is common and dangerous 6

  • Often mistaken for impetigo or bacterial superinfection
  • Delayed diagnosis can lead to serious complications including disseminated infection

Management of Secondary Infection

• If evidence of secondary bacterial infection exists:
  • Add appropriate systemic antibiotics targeting Staphylococcus aureus 2
  • Avoid topical antibiotics for long-term use due to risk of resistance 2

Important Considerations

• Avoid topical corticosteroids during active infection as they may worsen the condition 2, 6
• Resume appropriate eczema management after resolution of the herpetic infection
• Early treatment is crucial to prevent complications such as:
  • Disseminated infection
  • Keratoconjunctivitis
  • Potential mortality in severe cases

Follow-Up

• Reassess after 5-7 days of treatment
• If no improvement:
  • Consider resistance to acyclovir
  • Evaluate for other complications
  • Consider hospitalization for severe cases

Prevention in Recurrent Cases

• For patients with frequent recurrences:
  • Consider prophylactic antiviral therapy
  • Optimize management of underlying eczema to reduce flares
  • Educate about early recognition of symptoms

Common Pitfalls

• Delaying antiviral treatment while treating presumed bacterial infection 6
• Using topical antivirals alone (insufficient for eczema herpeticum)
• Failing to recognize the condition in patients with atopic dermatitis
• Continuing high-potency topical corticosteroids during active infection

Early recognition and prompt systemic antiviral therapy are essential for successful treatment of eczema herpeticum 4, 3, 7.