What is the treatment for a patient with eczema herpeticum presenting with fever?

Treatment of Eczema Herpeticum with Fever

For a patient with eczema herpeticum presenting with fever of 38.8°C, intravenous acyclovir should be administered immediately as the first-line treatment. 1

Diagnosis and Clinical Features

• Eczema herpeticum is characterized by disseminated viral infection with herpes simplex virus on eczematous skin, presenting as grouped, punched-out erosions or vesiculation 1
• Fever, lymphadenopathy, and malaise are common systemic manifestations 2
• The presence of dome-shaped papules/vesicles on areas affected by atopic dermatitis is characteristic 3
• Deterioration in previously stable atopic dermatitis may indicate secondary viral infection 1

Treatment Algorithm

First-line Treatment for Febrile Patients:

1. Intravenous acyclovir administration

   • Must be given early in the course of disease 1
   • Specifically indicated for ill, febrile patients 1
   • Delays in treatment can lead to increased morbidity and mortality 4

2. Supportive care

   • Antipyretics for fever management
   • Maintenance of hydration 5
   • Sedating antihistamines may help with pruritus during acute phase 1

3. Monitoring for complications

   • Assess for signs of systemic spread
   • Monitor for secondary bacterial infection 4

Secondary Bacterial Infection Management:

• If bacterial superinfection is suspected (indicated by crusting or weeping):
  • Flucloxacillin is the first-line antibiotic for Staphylococcus aureus (most common pathogen) 1
  • Erythromycin should be used in penicillin-allergic patients 1
  • Phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1

Risk Factors and Special Considerations

• Patients with extrinsic atopic dermatitis are at higher risk for eczema herpeticum 6
• Early onset of atopic dermatitis is associated with recurrent eczema herpeticum 6
• Herpetic lesions only appear on areas already affected by active atopic dermatitis 6
• Lymphopenia is commonly associated with eczema herpeticum 3

Important Clinical Pearls

• Do not use topical corticosteroids during active eczema herpeticum infection 3
• Systemic corticosteroids should be avoided during acute infection as they may worsen viral spread 5
• Eczema herpeticum can be mistaken for other conditions like Stevens-Johnson syndrome or impetigo 4
• After resolution of the acute infection, maintenance therapy for underlying atopic dermatitis should be resumed 1
• Recurrent episodes occur in some patients, requiring vigilance and early intervention 6

Prognosis

• With prompt antiviral treatment, most patients recover without complications 2
• Delayed treatment increases risk of dissemination and systemic complications 5
• Patients should be educated about recognizing early signs of recurrence 6