What is the recommended treatment for eczema herpeticum in children?

Treatment of Eczema Herpeticum in Children

Eczema herpeticum in children requires immediate treatment with systemic antiviral therapy, specifically acyclovir, which has transformed this condition from a potentially fatal disease with 10-50% mortality to one with zero mortality when treated appropriately. 1

Immediate Management

Systemic Antiviral Therapy

• Initiate acyclovir as early as possible upon clinical suspicion—earlier initiation directly correlates with shorter hospital stays and better outcomes 1
• Intravenous acyclovir is preferred for ill, febrile patients or those with severe, widespread disease 1, 2
• Oral acyclovir is appropriate for less severe cases and outpatient management 1, 3
• Valacyclovir has been successfully used orally in infants as young as 9 months, offering a convenient alternative for outpatient treatment 3

Route Selection Algorithm

• Use IV acyclovir if: Patient appears systemically ill, has fever, shows signs of dissemination, or is unable to tolerate oral medications 1, 4
• Use oral acyclovir/valacyclovir if: Patient is stable, afebrile, and can tolerate oral intake with localized disease 3

Clinical Recognition

Key Diagnostic Features

• Sudden onset of monomorphic vesicles that are punched-out, umbilicated, or crusted, appearing on pre-existing atopic dermatitis 3, 5
• Lesions resistant to topical corticosteroids that worsen despite standard eczema treatment 5
• Distribution typically on head, face, neck, and extremities where eczema is present 3

Common Pitfall

Eczema herpeticum is frequently misdiagnosed as atopic dermatitis exacerbation or bacterial superinfection, leading to inappropriate treatment with corticosteroids or antibiotics alone, which can worsen the condition 5, 4. The presence of discrete vesicles rather than diffuse weeping should raise suspicion for viral infection.

Concurrent Management

Discontinue Immunosuppressive Therapy

• Stop topical corticosteroids immediately when eczema herpeticum is suspected, as continued use can facilitate viral dissemination 5

Address Secondary Bacterial Infection

• Add antibiotics only if there is clinical evidence of concurrent bacterial infection (purulent exudate, pustules) 1
• Flucloxacillin is first-line for Staphylococcus aureus co-infection 1, 2

Evidence Strength

The recommendation for systemic antiviral therapy is based on compelling historical evidence: before acyclovir availability, eczema herpeticum carried 10-50% mortality 1. A large retrospective review of 1,331 children from 42 tertiary care pediatric hospitals demonstrated zero deaths when patients received systemic antiviral therapy 1. Multiple case series from the 1980s-1990s confirmed rapid clinical improvement with acyclovir, with dramatic drying of herpetic eruptions and resolution of systemic symptoms 6, 7.

High-Risk Populations

Infants with moderate to severe atopic dermatitis, food allergies, and marked eosinophilia are at highest risk for developing eczema herpeticum 5. Maintain heightened vigilance in this population, as the condition can develop rapidly and unpredictably, particularly in young infants 4.

Treatment Outcomes

• Rapid drying of herpetic eruptions typically occurs within days of initiating therapy 6
• Shorter duration of new lesion formation compared to untreated disease 6
• IV administration produces more dramatic improvement in general and local findings compared to oral administration 6
• No toxic side effects or visceral dissemination occurred in treated pediatric cohorts 6