What is the recommended treatment for a patient with eczema herpeticum and a history of Pseudomonas infection?

Treatment of Eczema Herpeticum with History of Pseudomonas Infection

Initiate systemic antiviral therapy with acyclovir immediately upon recognition of eczema herpeticum, while simultaneously continuing topical corticosteroids and adding appropriate antibacterial coverage for potential secondary bacterial infection, particularly given the patient's history of Pseudomonas. 1, 2

Immediate Recognition and Assessment

• Look for grouped vesicles, punched-out erosions, or sudden deterioration of previously stable eczema with fever—these are hallmark signs of eczema herpeticum and constitute a medical emergency 1, 2
• Assess for signs of secondary bacterial superinfection including increased crusting, weeping lesions, pustules, or increased exudate, which commonly coexist with eczema herpeticum 1
• Send a viral swab for electron microscopy confirmation, though treatment should not be delayed pending results 1

Primary Antiviral Treatment Algorithm

For outpatient management (mild to moderate cases):

• Oral acyclovir 200 mg five times daily for 5-10 days, initiated as early as possible in the disease course 3, 4, 5
• Alternative: Valacyclovir 500 mg twice daily (better bioavailability, more convenient dosing) 6

For hospitalized or severely ill patients:

• IV acyclovir 5 mg/kg infused over 1 hour every 8 hours for 7 days in adults and adolescents ≥12 years 1, 4
• Pediatric patients <12 years: IV acyclovir 10 mg/kg infused over 1 hour every 8 hours for 7 days 4
• This route is mandatory for ill, feverish patients or those with signs of systemic involvement 1, 2

Concurrent Antibacterial Coverage

Given the patient's Pseudomonas history, antibacterial therapy is critical:

• First-line for typical Staphylococcus aureus coverage: Flucloxacillin orally 1, 2
• For Pseudomonas coverage or MRSA concern: Consider clindamycin 600 mg IV/PO three times daily or vancomycin IV for severe infections 1
• Alternative for multidrug-resistant organisms: Linezolid 600 mg PO/IV twice daily 1
• Continue therapy for 7-14 days based on clinical response 1

Essential Concurrent Topical Management

• Continue topical corticosteroids throughout the infection—do not discontinue them 1, 2
• Apply topical corticosteroids twice daily to affected eczematous areas using appropriate potency for the body site 1, 2
• Liberal emollient application, especially after bathing, to maintain skin barrier function 1, 2
• Use soap-free cleansers and avoid irritants 1

Monitoring and Follow-up

• Reassess after 2-4 days to confirm clinical improvement 1
• If no response by 2-4 days, obtain bacteriological swabs to guide antibiotic adjustment 1
• Watch for complications including meningitis, encephalitis, acute liver failure, or sepsis, which can occur without appropriate treatment 7, 8

Critical Pitfalls to Avoid

• Never delay or withhold topical corticosteroids when infection is present—they remain essential primary treatment when appropriate systemic antimicrobials are given concurrently 1, 2
• Do not mistake eczema herpeticum for Stevens-Johnson syndrome; eczema herpeticum lacks the atypical target lesions, flaccid bullae, and prominent mucosal involvement seen in Stevens-Johnson syndrome 8
• Do not use topical acyclovir alone—systemic therapy is required for this disseminated infection 9
• Avoid delaying IV acyclovir in severely ill or febrile patients; oral therapy is insufficient in these cases 1, 2

Special Considerations for Pseudomonas History

• Patients with prior Pseudomonas infection require broader antibacterial coverage than standard flucloxacillin 1
• Consider early escalation to anti-pseudomonal antibiotics if clinical response is inadequate within 48-72 hours 1
• Eczema herpeticum requires active AD lesions for clinical manifestation—herpetic lesions never occur on skin without underlying eczema 10