Can children have mild cases of eczema herpeticum?

Can Children Have Mild Cases of Eczema Herpeticum?

No, eczema herpeticum in children does not typically present as a "mild" condition and should always be treated as a potentially serious, rapidly progressive infection requiring prompt systemic antiviral therapy. While the severity of presentation may vary, this is a medical emergency that can lead to significant morbidity and mortality if not recognized and treated early 1.

Clinical Presentation and Recognition

Eczema herpeticum presents as a disseminated cutaneous herpes simplex virus infection that develops in children with atopic dermatitis, though the underlying eczema itself may not be particularly severe or active at the time 1. The key clinical features include:

• Characteristic lesions: Multiple uniform, "punched-out" erosions or vesiculopustular eruptions that are very similar in shape and size 2, 1
• Rapid progression: The condition can spread quickly across the skin surface 1
• Systemic involvement: 56% of children present with fever, 37% have systemic symptoms, and 10% develop eye involvement (keratoconjunctivitis) 3
• Generalized distribution: 76% of pediatric patients have generalized eruptions at presentation 3

Why "Mild" Cases Are Misleading

The concept of "mild" eczema herpeticum is clinically problematic because:

• Risk of rapid deterioration: Even if initial presentation appears limited, the infection can progress rapidly to viraemia and secondary septicaemia 1
• Life-threatening potential: This is explicitly described as a "potentially life-threatening disseminated cutaneous viral infection" 4
• High hospitalization rate: 57% of pediatric patients with eczema herpeticum require hospitalization 3
• Diagnostic confusion: Cases are frequently misdiagnosed as simple atopic dermatitis exacerbations, particularly in infants with moderate to severe AD 5

High-Risk Populations

Certain children are at particularly high risk for severe presentations requiring hospitalization 3:

• Age under 1 year (OR = 7.17)
• Male sex (OR = 3.09)
• Presence of fever (OR = 5.75)
• Systemic symptoms (OR = 2.84)

Critical Management Principles

All suspected cases require immediate systemic antiviral therapy with acyclovir 2, 4. The Taiwan Academy of Pediatric Allergy, Asthma and Immunology explicitly states that systemic antiviral therapy is indicated for eczema herpeticum, as it "may progress rapidly to systemic infection in the absence of antiviral therapy" 2.

Treatment approach includes:

• Intravenous acyclovir for hospitalized or systemically unwell children 4
• Empirical antibiotics (such as cephalexin or flucloxacillin) to cover secondary bacterial infection 6, 4
• Topical antimicrobials (fusidic acid) as adjunctive therapy 4

Common Diagnostic Pitfalls

The most dangerous error is mistaking eczema herpeticum for simple bacterial superinfection or eczema flare 5. Key distinguishing features:

• Uniform lesion morphology: The presence of many similarly shaped and sized eroded lesions is a crucial diagnostic clue 1
• Resistance to topical corticosteroids: New vesiculopustular lesions that don't respond to TCS therapy should raise suspicion 5
• Rapid deterioration: A child with eczema who becomes systemically unwell with rapid worsening should prompt immediate consideration of eczema herpeticum 1

Recurrence Risk

Children who experience one episode are at risk for future episodes:

• Recurrence rate (<1 month): 8.9% 3
• Repeat episodes (>1 month): 16% 3
• Hospitalized patients have increased likelihood of repeat episodes (OR = 8.25) 3
• Previous history significantly increases risk of both early recurrence (OR = 6.80) and repeat episodes (OR = 9.43) 3

Bottom Line

While the extent of skin involvement may vary between patients, eczema herpeticum should never be dismissed as "mild" in clinical practice. Early recognition through identification of characteristic uniform erosions, prompt virological confirmation when possible, and immediate initiation of systemic acyclovir are essential to prevent serious complications 1. Any child with atopic dermatitis who develops grouped, punched-out erosions or vesiculation with systemic symptoms requires urgent evaluation and treatment 2.