What is the treatment for Eczema Herpeticum?

Treatment of Eczema Herpeticum

Eczema herpeticum requires immediate treatment with systemic antiviral therapy, specifically oral acyclovir at a dose of 200 mg five times daily for five days, which has shown an 81.3% efficacy rate compared to 42.9% with placebo. 1

Diagnosis and Clinical Presentation

Eczema herpeticum is a rapidly progressing skin complication caused by herpes simplex virus infection in patients with pre-existing skin conditions, particularly atopic dermatitis. It presents with:

• Cutaneous pain and scaling
• Vesicular lesions that can rapidly spread
• Potential for secondary bacterial infection
• Fever and malaise 2, 3

It's important to differentiate eczema herpeticum from other conditions like impetigo, Stevens-Johnson syndrome, disseminated herpes zoster, and acute generalized exanthematous pustulosis 2.

Treatment Algorithm

1. First-Line Treatment

• Systemic antiviral therapy
  • Oral acyclovir 200 mg five times daily for five days 1
  • Begin immediately upon diagnosis to prevent serious complications 3, 4

2. Management of Secondary Infection

• If secondary bacterial infection is present:
  • Appropriate antibiotic therapy
  • Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 5

3. Supportive Care for Underlying Skin Condition

• For underlying atopic dermatitis:
  • Apply fragrance-free emollients multiple times daily 5
  • Avoid high-potency topical corticosteroids during active infection as they may worsen viral spread

Risk Factors and Prevention

Patients at highest risk for eczema herpeticum include those with:

• Extrinsic atopic dermatitis (AD with elevated IgE levels) 6
• Early onset of atopic dermatitis (associated with recurrent eczema herpeticum) 6
• Compromised immune systems 2

Important Clinical Considerations

• Delay in diagnosis and treatment can lead to severe morbidity and mortality 2, 4
• Herpetic lesions only appear on areas with active atopic dermatitis lesions 6
• Recurrent eczema herpeticum is associated with more severe atopic distortion 6

Common Pitfalls and Caveats

• Misdiagnosis: Eczema herpeticum is often initially misdiagnosed as impetigo or a flare of underlying atopic dermatitis, leading to inappropriate treatment with antibiotics or topical steroids alone 3
• Inappropriate treatment: Using topical steroids without antiviral therapy may worsen the condition
• Delayed treatment: Failure to recognize and treat promptly can lead to serious complications including systemic infection 4

Early recognition and prompt initiation of antiviral therapy are essential to prevent complications and achieve rapid resolution of symptoms 3, 4.