What is the treatment for herpetic dermatitis on the face in an 8-year-old (YOM: years old male) child weighing 27 kilograms?

Treatment of Herpetic Dermatitis (Eczema Herpeticum) on the Face in an 8-Year-Old Child

Initiate oral acyclovir immediately at 20 mg/kg per dose (maximum 400 mg/dose) three times daily for 5-10 days, as this is a dermatologic emergency requiring prompt antiviral therapy to prevent significant morbidity and potential mortality. 1

Immediate Recognition and Treatment Initiation

• Eczema herpeticum is a dermatologic urgency that requires immediate recognition and treatment due to increased patient morbidity 1
• Before the use of acyclovir, there was a 10-50% mortality rate for untreated eczema herpeticum patients 1
• A retrospective review of 1,331 children from 42 tertiary care pediatric hospitals demonstrated that no deaths occurred from eczema herpeticum when patients received systemic antiviral therapy 1
• Earlier medication initiation directly correlates with decreased length of hospital stay, further supporting acyclovir's efficacy 1

Specific Dosing for This Patient

For this 8-year-old child weighing 27 kg with mild to moderate disease:

• Oral acyclovir 20 mg/kg per dose (540 mg, rounded to 400-500 mg based on available formulations) three times daily for 5-10 days 1
• The maximum dose per administration is 400 mg, so this child would receive 400 mg three times daily 1

If the child appears ill, febrile, or has extensive facial involvement:

• Administer intravenous acyclovir 5-10 mg/kg per dose (135-270 mg for this 27 kg child) three times daily 1, 2
• After lesions begin to regress, transition to oral acyclovir and continue therapy until lesions completely heal 1

Clinical Recognition Features

• Look for grouped vesicles, punched-out erosions, or sudden deterioration of pre-existing eczema with fever 3, 4
• The presentation typically includes monomorphic vesicles that may become pustular, with crusting and weeping 5, 2
• Facial involvement is common in children, particularly affecting areas of pre-existing atopic dermatitis 4, 2

Concurrent Management Strategies

Continue topical corticosteroids during treatment:

• Do not discontinue topical corticosteroids when infection is present - they remain primary treatment when appropriate systemic antivirals are given concurrently 1, 3
• Use mild to moderate potency topical corticosteroids on the face, such as hydrocortisone 1-2.5%, as facial skin is thinner and at higher risk for atrophy 6

Maintain emollient therapy:

• Continue liberal application of emollients throughout treatment to support skin barrier function 3, 4
• Apply emollients immediately after bathing when skin is most hydrated 4

Consider bacterial superinfection:

• Watch for increased crusting, weeping, or pustules suggesting secondary bacterial infection with Staphylococcus aureus 3, 4
• If bacterial infection is suspected, add flucloxacillin while continuing acyclovir therapy 3, 4

Alternative Antiviral Options

• Valacyclovir may be used in older children able to swallow tablets at adult dosing (1 g orally twice daily), though no pediatric preparation exists and data on dosing in children are limited 1, 5
• One case report demonstrated successful treatment of HSV-2-associated eczema herpeticum in a 9-month-old infant with oral valacyclovir, suggesting it may be an effective and convenient option for pediatric outpatients 5

Critical Pitfalls to Avoid

• Never delay antiviral therapy - timing of acyclovir initiation directly relates to clinical outcomes and length of illness 1
• Do not mistake eczema herpeticum for bacterial infection alone - the presence of grouped vesicles and punched-out erosions distinguishes this from simple bacterial superinfection 3, 2
• Avoid using corticosteroids alone without concurrent antiviral therapy - one case report showed worsening eruptions after treatment with dexamethasone alone before the correct diagnosis was made 5
• Do not use very potent corticosteroids on facial skin - the face is a thin-skinned area at higher risk for atrophy and adverse effects 3, 6

Monitoring and Follow-Up

• Assess clinical response within 48-72 hours of initiating antiviral therapy 2
• Expect fever resolution and partial involution of rash within 2 days of appropriate antimicrobial therapy 2
• Continue treatment until complete healing of all lesions 1
• Educate parents about preventing HSV transmission by avoiding direct contact with individuals who have active herpetic lesions 7