eczema

A 3-year-old male with a history of severe atopic dermatitis presented for facial rash and hand pain. Mom had been applying Aquaphor and Vaseline several times a day. On the day of presentation, he woke up with a new rash over his face and hands which prompted the ED visit. He is up to date on childhood immunizations and is not prescribed any oral medications.

 

Vitals: BP 103/61; HR 156; Temp 102.9°F; RR 30; SpO2 99%.

General: He appears in no acute distress, acting appropriately for age. Interacts and follows commands. Scratching himself all over.

Skin: Diffuse, itchy, dry skin throughout and findings noted in the attached images most notably erythematous pustules on the dorsal hands and peri-oral lesions in addition to punched-out ulcerations on the philtrum. Lesions are tender to palpation and spare mucous membranes and palms/soles. Nikolsky sign negative.

WBC: 12.96

Skin scraping: +VZV

This patient has Eczema herpeticum as demonstrated by multiple grouped pustules on an erythematous base.

Ophthalmology should be consulted to rule out ocular involvement most notably herpes zoster ophthalmicus.

Take-Home Points

  • Eczema herpeticum is typically caused by superinfection of Herpes Simplex Virus due to a diminished skin barrier from atopic dermatitis. It is commonly misdiagnosed as impetigo. Grouped vesicles/pustules on an erythematous base and tenderness to palpation should prompt the physician to suspect herpetic skin infection.
  • Eczema herpeticum may be potentially life-threatening if it has spread to multi-system involvement such as HSV keratitis or encephalitis.
  • Treatment includes acyclovir in addition to gram positive coverage such as TMP/SMX or cephalexin.

  • American Academy of Pediatrics: Herpes simplex. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:432–445.
  • Studdiford JS, Valko GP, Belin LJ, Stonehouse AR. Eczema herpeticum: making the diagnosis in the emergency department. J Emerg Med. 2011 Feb;40(2):167-9. doi: 10.1016/j.jemermed.2007.11.049. Epub 2008 Jun 27. PMID: 18584994.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Edward Guo, MD

Edward Guo, MD

Emergency Medicine Resident
Cooper University Healthcare

Michael Gillman, MD

Pediatric Emergency Medicine Physician
Assistant Professor of Emergency Medicine
Cooper University Healthcare

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