Increasing redness, warmth, swelling, or pus suggesting bacterial infection
Systemic deterioration
High fever (greater than 39 C) not responding to acetaminophen or ibuprofen
Inability to keep food or fluids down
Signs of dehydration (dry mouth, no tears, no urination for more than 8 hours in children)
Follow-up plan
Primary care or dermatology follow-up within 24 to 48 hours
To confirm lesions are crusting and improving
To assess antibiotic need if skin infection signs develop
Dermatology follow-up within 1 to 2 weeks
To optimize eczema management and reduce recurrence risk
Discussion of long-term treatment options (dupilumab)
Expected recovery course
Lesions should begin crusting within 2 to 3 days of starting antivirals
Full resolution typically in 1 to 2 weeks
Some scarring possible at heavily affected sites
Recurrence awareness
Approximately 9% recurrence within 1 month
Contact your doctor promptly at first sign of recurrence for early treatment
References
Guidelines and key sources
Primary clinical references
Damour A et al. Eczema Herpeticum: Clinical and Pathophysiological Aspects. Clinical Reviews in Allergy and Immunology. 2020. PMID 31836943
Comprehensive review of pathophysiology and management
Filaggrin and antimicrobial peptide deficiency in EH risk
Wollenberg A et al. Predisposing Factors and Clinical Features of Eczema Herpeticum: A Retrospective Analysis of 100 Cases. JAAD. 2003. PMID 12894065
Largest retrospective series defining clinical features
Topical steroids safe to continue during EH
Luca NJ et al. Eczema Herpeticum in Children: Clinical Features and Factors Predictive of Hospitalization. Journal of Pediatrics. 2012. PMID 22575249
Age less than 1 year as predictor of hospitalization (OR 7.17)
Periocular involvement in 10% of pediatric cases
Emergency medicine and laboratory references
Studdiford JS et al. Eczema Herpeticum: Making the Diagnosis in the Emergency Department. Journal of Emergency Medicine. 2011. PMID 18584994
ED-focused approach to EH diagnosis and management
Impetigo as most common misdiagnosis
Aronson PL et al. Delayed Acyclovir and Outcomes of Children Hospitalized With Eczema Herpeticum. Pediatrics. 2011. PMID 22084327
Delayed acyclovir associated with longer hospitalization and complications
Supports immediate empiric antiviral therapy
Miller JM et al. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update. IDSA and ASM. Clinical Infectious Diseases. 2024
NAAT preferred over culture for cutaneous HSV diagnosis
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