Eczema HerpeticumMANAGEMENT

DERMATOLOGY PRESENTATIONS · 12 SECTIONS

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644 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Allergic contact dermatitis Bullous Pemphigoid Cutaneous Abscess DRESS syndrome Eczema Herpeticum Erysipelas Erythema multiforme Henoch-Schönlein purpura Herpes Zoster (Shingles)Herpetic Whitlow Hidradenitis suppurativa Paronychia Pediculosis (Lice)Pemphigus Vulgaris Pilonidal Abscess Pressure injury Psoriasis (acute flare)Psoriasis Flare Staphylococcal Scalded Skin Syndrome Stevens-Johnson Syndrome (SJS)Toxic Epidermal Necrolysis (TEN)Urticaria (acute)Warfarin-induced Skin Necrosis

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp45

Immediate priorities

›Dermatologic emergency recognition

›Known atopic dermatitis with acute painful vesicular eruption

›Rapid onset over 1 to 3 days

›Fever present in 56 to 59% of cases

›Monomorphic punched-out erosions in areas of active eczema

›Hallmark distinguishing feature

›Painful not merely pruritic

›Do not wait for confirmatory testing before initiating antivirals

›Clinical diagnosis sufficient to start acyclovir

›Delay in antiviral therapy worsens pediatric outcomes

Critical alarm features

›High-risk features requiring urgent escalation

›Periocular involvement

›HSV keratoconjunctivitis risk in approximately 10% of pediatric cases

›Mandatory fluorescein eye exam and ophthalmology consult

›Hemodynamic instability suggesting viremia or sepsis

›S. aureus bacteremia occurs in approximately 3.9% of hospitalized cases

›Broad-spectrum antibiotics if septic shock

›Age less than 1 year

›Strongest predictor of hospitalization (OR 7.17)

›Low threshold for IV acyclovir and admission

›Immunocompromised host

›HIV, organ transplant, or chemotherapy

›Higher risk of viral dissemination and multiorgan failure

›Concern for HSV encephalitis

›Altered mental status, seizures, or focal neurologic deficits

›CT head and LP if encephalitis suspected

02History/hx49

Presenting symptoms

›Classic symptom cluster

›Acute onset painful burning vesiculopapular eruption

›Rapid progression over 1 to 3 days

›Pain predominates over itch

›Fever and systemic illness

›Malaise and fatigue

›Poor oral intake especially in children

›Lymphadenopathy

›Regional or generalized

›Associated with viremia

Exposure and contact history

›HSV exposure

›Personal history of orolabial herpes or genital herpes

›Recurrent cold sores in patient or close contacts

›Prior genital HSV-2 diagnosis

›Contact history

›Household member with active cold sores

›Wrestling contact sport exposure (herpes gladiatorum risk)

›Daycare exposure in children

Atopic dermatitis background

›Underlying skin disease context

›Severity and duration of atopic dermatitis

›Early-onset AD associated with higher EH risk

›Severe AD with high total serum IgE predicts EH

›Current and recent AD therapies

›Topical calcineurin inhibitor use increases EH risk

›Systemic immunosuppressants including dupilumab status

03Physical Exam/exam51

Vital signs

›Hemodynamic and temperature assessment

›Temperature

›Fever present in 56 to 59% of cases

›High fever with rigors raises concern for bacteremia

›Heart rate

›Tachycardia suggesting systemic illness or dehydration

›Hemodynamic instability (HR >120, SBP <90 mmHg) triggers IV resuscitation

›Blood pressure

›SBP <90 mmHg requires immediate fluid resuscitation

›MAP <65 mmHg as septic shock threshold

Skin examination

›Morphology and distribution

›Monomorphic dome-shaped vesicles

›Uniform size distinguishes EH from varicella (polymorphic stages)

›Concentrated in areas of pre-existing eczema

›Punched-out erosions with scalloped borders

›Hallmark of EH after vesicle rupture

›Hemorrhagic crusting as lesions evolve

›Distribution pattern

›Head, neck, and trunk most commonly affected

›Follows pre-existing eczematous skin

›Secondary infection signs

›Purulence or expanding cellulitis

›S. aureus co-infection in approximately 30% of hospitalized cases

›Warmth and erythema beyond primary vesicle field

›Lesion count and spread

›Extensive eruption suggests need for admission

04Differential Diagnosis/ddx43

Life-threatening diagnoses

›Critical mimics requiring urgent differentiation

›HSV encephalitis

›ICD-10 B00.4

›Altered mental status, seizures, focal deficits with EH

›Disseminated HSV with sepsis

›ICD-10 B00.7

›Multiorgan failure, hemodynamic instability

›Secondary bacterial sepsis (S. aureus)

›ICD-10 A41.01 (MSSA) or A41.02 (MRSA)

›Bacteremia in approximately 3.9% of hospitalized EH patients

Common mimics

›Skin infection and inflammatory mimics

›Impetigo

›ICD-10 L01.0

›Most common ED misdiagnosis for EH

›Honey-crusted lesions without monomorphic vesicles, responds to antibiotics alone

›Varicella (chickenpox)

›ICD-10 B01.9

›Polymorphic lesions in multiple stages; no underlying eczematous background

›VZV PCR distinguishes

›Eczema coxsackium (hand-foot-mouth variant)

›ICD-10 B08.4

›Polymorphous vesicles, acral distribution (palms, soles), oral lesions concurrent

›Coxsackievirus A6 most common strain

›Disseminated herpes zoster

›ICD-10 B02.9

›Dermatomal onset before dissemination

05Laboratory Tests/lt54

Viral diagnostic tests

›HSV nucleic acid amplification test (NAAT/PCR)

›Gold standard for HSV diagnosis

›Highest sensitivity and specificity for HSV detection

›Specimen from vesicle base scraping or swab of fresh erosion

›PCR from Tzanck smear debris

›Same slide used for Tzanck and PCR increases diagnostic yield

›IDSA/ASM 2024 guideline recommends NAAT over culture for cutaneous HSV

›Tzanck smear

›Rapid bedside point-of-care test

›Sensitivity 60 to 77%, specificity approximately 100% for herpetic infection

›Unroof fresh vesicle, scrape base and roof, stain with Giemsa or Wright stain

›Findings

›Multinucleated giant cells

›Ballooning degeneration of keratinocytes

›Cannot distinguish HSV from VZV

›VZV PCR required for differentiation if zoster suspected

›Viral culture

›Confirmatory option if PCR unavailable

›Less sensitive than PCR

›Result in 1 to 3 days

›Direct fluorescent antibody (DFA)

›Rapid but sensitivity less than 75%

›Can distinguish HSV from VZV

Hematology and inflammatory markers

›Complete blood count

›Lymphopenia associated with EH diagnosis

›Lymphocyte count as supportive finding

06Diagnostic Tests/dt60

Scoring Systems

›EH severity stratification framework

›Mild/localized disease

›Limited vesicles, no fever, well-appearing patient

›May be managed outpatient with oral antivirals

›Moderate to severe disease

›Widespread eruption, fever, systemic symptoms

›Age less than 1 year, periocular involvement

›Requires hospitalization for IV acyclovir

›Critical disease

›Signs of viremia, sepsis, encephalitis, or multiorgan involvement

›ICU admission required (approximately 3.8% of hospitalized cases)

›Risk stratification factors (Luca et al. 2012, Pediatrics)

›Age less than 1 year as independent predictor of hospitalization (OR 7.17)

›Lower threshold for admission in infants

›IV antiviral preferred over oral in this age group

›Periocular involvement requiring ophthalmology

›Same-day consult mandatory

›Topical antiviral drops (trifluridine) adjunct if keratitis confirmed

MRI

›MRI brain indications for EH

›HSV encephalitis concern

›Altered mental status, new seizures, or focal neurologic deficits

›T2/FLAIR hyperintensity in temporal lobes is hallmark of HSV encephalitis

›MRI superior to CT for early encephalitis detection

›CT may be normal in early HSV encephalitis

›MRI brain with and without contrast preferred

›Lumbar puncture should accompany brain MRI

07Disposition/dispo46

Admission indications

›Criteria for hospital admission

›Systemic illness markers

›Fever or tachycardia present

›Systemic symptoms including malaise, lymphadenopathy

›Age and vulnerability factors

›Age less than 1 year (strongest independent predictor OR 7.17)

›Immunocompromised host (HIV, transplant, chemotherapy)

›Disease extent and severity

›Widespread or generalized eruption

›Periocular involvement

›Rapidly spreading lesions

›Inability to manage outpatient

›Inability to tolerate oral medications

›Unable to ensure reliable follow-up within 24 to 48 hours

›Complication concerns

›Signs of secondary bacterial sepsis

›Concern for HSV encephalitis or disseminated HSV

›Dehydration with poor oral intake (especially children)

ICU indications

›Critical level of care criteria

›Hemodynamic compromise

›Septic shock (MAP <65 mmHg, lactate >=2 mmol/l)

›Vasopressor requirement

›Neurologic involvement

›HSV encephalitis (approximately 3.8% of hospitalized cases require ICU)

›Seizures or coma

›Respiratory compromise

08Treatment/t68

Antiviral therapy

›IV acyclovir for severe or hospitalized cases

›Adult dosing

›Acyclovir 5 to 10 mg/kg IV every 8 hours

›Duration 7 to 14 days depending on severity and response

›Renal dosing adjustment required

›Creatinine clearance 25 to 50 ml/min: every 12 hours

›Creatinine clearance 10 to 25 ml/min: every 24 hours

›Hemodialysis: supplemental dose after each session

›Adequate hydration required to prevent crystalline nephropathy

›IV fluids at 125 to 150 ml/h during infusion

›Monitor urine output and creatinine

›Oral antiviral for mild to moderate localized disease

›Acyclovir oral

›400 mg 5 times daily for 5 to 10 days

›Older regimen: 200 mg 5 times daily

›Valacyclovir oral (preferred for better bioavailability)

›1 g twice daily for 7 to 10 days in adults

›Better compliance than acyclovir 5 times daily

›Famciclovir oral

›500 mg three times daily for 7 days

›Alternative if valacyclovir unavailable

›Acyclovir-resistant HSV considerations

›Suspect in immunocompromised patients failing standard therapy

›Resistance mediated by thymidine kinase mutations

›Foscarnet 40 mg/kg IV every 8 hours as alternative

›Cidofovir as second-line option

›5 mg/kg IV weekly with probenecid

›Nephrotoxic; renal monitoring required

Adjunctive and supportive care

›Atopic dermatitis management during EH

›Continue topical corticosteroids

›Do NOT withhold topical steroids during EH

›Studies show topical steroids do not prolong hospitalization or worsen EH

›Class I evidence: topical steroid continuation supported

›Hold topical calcineurin inhibitors during active infection

›Tacrolimus and pimecrolimus associated with increased EH risk

›Resume after full resolution of EH

›Bacterial superinfection management

›Empiric antibiotics for S. aureus when superinfection suspected

›Cephalexin 500 mg four times daily for 7 days (outpatient)

›TMP-SMX for MRSA concern outpatient (1 to 2 DS tablets twice daily)

›IV antibiotics for septic presentation

›Nafcillin or oxacillin 2 g IV every 4 hours (MSSA)

›Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours (MRSA concern)

›S. aureus co-infection in approximately 30% of hospitalized EH cases

›Ocular treatment if keratoconjunctivitis

›Ophthalmology to direct ocular antiviral therapy

›Trifluridine 1% ophthalmic drops 9 times daily for 7 to 14 days

›Alternative: ganciclovir 0.15% ophthalmic gel 5 times daily

›Topical steroids contraindicated in active HSV keratitis

›Can cause stromal melting and perforation

›Only under ophthalmology direction

Pain and fever management

›Analgesia and antipyretics

›Acetaminophen for fever and pain

›650 to 1000 mg every 4 to 6 hours (adult)

›Weight-based dosing in children: 15 mg/kg every 4 to 6 hours

›NSAIDs for pain if no contraindications

›Ibuprofen 400 to 600 mg every 6 to 8 hours with food

›Avoid in renal impairment and concurrent acyclovir nephrotoxicity risk

›Topical lidocaine or barrier creams for local wound pain

›Lidocaine 2% gel to erosive lesions

›Wound care for crusted lesions

Fluid and nutritional support

›Hydration management

›Oral rehydration for mild cases tolerating fluids

›Monitor intake and output especially in febrile children

›Electrolyte solution for significant dehydration

›IV fluid resuscitation for sepsis or dehydration

›Normal saline or lactated Ringer's 20 to 30 ml/kg bolus for shock

›Maintenance IV fluids for inability to tolerate oral intake

09Special Populations/sp86

Pregnancy

›Maternal risks and fetal considerations

›Maternal EH risk profile

›Atopic dermatitis is common in women of childbearing age

›Pregnancy-associated immunologic changes may alter presentation

›Fetal and neonatal transmission risk

›Active HSV infection near term raises neonatal herpes risk

›Obstetric consultation mandatory for active HSV near delivery

›Neonatal herpes mortality 40 to 60% if untreated

›Antiviral safety in pregnancy

›Acyclovir

›Generally considered safe in pregnancy (Category B)

›IV acyclovir indicated for severe EH in pregnancy without dose modification

›Extensive clinical experience in pregnancy; no teratogenicity demonstrated

›Valacyclovir

›Also considered safe; prodrug of acyclovir

›500 mg to 1 g twice daily for mild EH in pregnancy

›Famciclovir

›Limited human data; generally avoided in first trimester

›Prefer acyclovir or valacyclovir in pregnancy

›Antibiotic selection for bacterial co-infection in pregnancy

›Cephalexin 500 mg four times daily is safe in pregnancy

›First-line for MSSA superinfection

›Avoid TMP-SMX in first trimester and near term

›Neural tube defect risk in first trimester

›Neonatal jaundice risk near term

›Clindamycin 300 mg three times daily as alternative

›Safe in all trimesters

Geriatric

›Age-related considerations

›Atypical presentation patterns

›Fever may be blunted or absent

›Systemic symptoms may be subtle

›Delirium as primary presentation

›Underlying skin changes

›Skin atrophy increases fragility of lesions

›Slower wound healing prolongs recovery

›Itch may predominate in older patients with atopic diathesis

›Medication adjustments in older adults

›Renal function assessment critical

›Age-related decline in GFR common

›Acyclovir dose adjust based on calculated creatinine clearance

›Crystalline nephropathy risk higher with baseline renal impairment

›Drug interactions in polypharmacy

›Valacyclovir and nephrotoxic medications

›Monitor closely for CNS toxicity (confusion, tremor) with acyclovir

›Hydration support

›Higher risk of dehydration with fever and poor intake

›Lower threshold for IV fluids and admission

›Disposition considerations

›Lower threshold for hospital admission

›Limited home support and frailty

›Cognitive impairment affects medication adherence

›Social support assessment mandatory before discharge

Pediatrics

›Age-specific risk and presentation

›Highest risk in infants less than 1 year

›Hospitalization OR 7.17 compared to older children

›More likely to develop systemic complications

›Clinical features in children

›Fever very common in pediatric EH

›Periocular involvement in approximately 10% of pediatric cases

›Poor oral intake and dehydration frequent concern

›Neonates (less than 4 weeks)

›Highest mortality risk from HSV

›Neonatal HSV treated with IV acyclovir 20 mg/kg every 8 hours

›Immediate neonatology or pediatric ID consultation

›Pediatric antiviral dosing

›IV acyclovir for moderate to severe pediatric EH

›Children: 10 to 20 mg/kg IV every 8 hours (age-dependent)

›Neonates: 20 mg/kg IV every 8 hours for 14 to 21 days

›Adjust for renal function

›Oral valacyclovir for mild pediatric EH

›Children 2 to 18 years: 20 mg/kg per dose (max 1 g) twice daily

›Duration 5 to 10 days based on severity

›Oral acyclovir alternative

›Children under 2 years: weight-based dosing per ID guidance

›80 mg/kg per day divided 4 to 5 times daily (max 3200 mg/day)

›Pediatric antibiotic dosing for superinfection

›Cephalexin oral

›25 to 50 mg/kg per day divided every 6 hours (max 4 g/day)

›For mild S. aureus superinfection

›Nafcillin IV for MSSA bacteremia

›150 to 200 mg/kg per day divided every 4 to 6 hours

›Adjust based on culture sensitivities

›Delayed acyclovir in pediatric EH

›Aronson et al. 2011 (Pediatrics) showed delayed acyclovir worsens outcomes

›Longer hospitalization and higher complication rates

›Initiate acyclovir immediately upon clinical suspicion

10Background/b73

Epidemiology

›Prevalence and incidence

›Eczema herpeticum occurs in approximately 3% of atopic dermatitis patients

›AD prevalence 15 to 20% in children and 1 to 3% in adults globally

›Annual incidence of EH estimated at 1 per 5000 in atopic dermatitis populations

›Age distribution

›Most common in infants and young children with severe AD

›Second peak in adults with severe undertreated AD

›Median age approximately 2 to 5 years in pediatric series

›Mortality and morbidity

›Pre-acyclovir era mortality 10 to 50%

›Acyclovir dramatically reduced mortality

›Current mortality less than 1 to 2% with appropriate treatment

›Hospitalization burden

›ICU admission required in approximately 3.8% of hospitalized cases

›S. aureus bacteremia in approximately 3.9% of hospitalized patients

›Causative agents

›HSV-1 accounts for majority of cases

›HSV-2 accounts for minority especially with genital source exposure

Pathophysiology

›Skin barrier dysfunction

›Filaggrin gene mutation role

›Filaggrin is essential for epidermal barrier integrity

›Loss-of-function mutations found in 30 to 50% of AD patients

›Disrupted barrier allows HSV penetration

›Reduced antimicrobial peptides

›LL-37 (cathelicidin) and human beta-defensins markedly reduced in AD skin

›Antimicrobial peptides normally suppress HSV replication

›Deficiency allows viral amplification at skin surface

›Immunologic susceptibility

›Th2-skewed immune response in atopic dermatitis

›IL-4, IL-13, IL-31, IL-33 dominant cytokine profile

›Th2 skewing impairs antiviral IFN-gamma responses

›S. aureus synergy with HSV

›S. aureus alpha-toxin promotes HSV-1 replication

›Colonization present in over 90% of AD skin

›Biofilm disrupts epidermal tight junctions

›Dupilumab effect

›IL-4/IL-13 receptor antagonist reduces EH risk in AD patients

›Mechanism includes restoration of skin barrier and antimicrobial peptides

›HSV pathogenesis in EH

›Viral entry through disrupted epidermal barrier

›Replication in keratinocytes of affected skin

›Cell-to-cell spread causing coalescent vesicles

›Viremia in severe cases

›Hematogenous spread to viscera

›HSV encephalitis via retrograde axonal transport

›Hepatitis, pneumonitis in immunocompromised

Therapeutic Considerations

›Antiviral strategy principles

›Never delay therapy pending confirmatory results

›Clinical diagnosis sufficient to initiate acyclovir

›Delayed acyclovir in children associated with worse outcomes (Aronson 2011)

›Route selection based on severity

›IV acyclovir for hospitalized, severe, disseminated, or periocular cases

›Oral valacyclovir for mild localized outpatient disease

›Duration 7 to 14 days

›Guided by lesion crusting and systemic symptom resolution

›Longer duration for immunocompromised patients

›Topical corticosteroid continuation rationale

›Evidence supports continuation during EH treatment

›Wollenberg et al. 2003 series (100 cases): no worsening with topical steroids

›Hemani et al. 2020: topical steroid use did not increase hospitalization duration

›Untreated underlying AD prolongs EH vulnerability

›Skin barrier restoration reduces future EH episodes

›Dupilumab reduces EH recurrence by improving baseline AD control

›Recurrence prevention

›Suppressive antiviral therapy for recurrent EH

›Acyclovir 400 mg twice daily or valacyclovir 500 mg daily

›Indicated after two or more EH episodes

›Optimize AD control

›Dupilumab reduces EH risk substantially

›Aggressive moisturization and topical steroid regimens

›Infection control measures

›Avoid contact with individuals with active herpes labialis

›Avoid contact sports during active EH (herpes gladiatorum transmission)

11Patient Discharge Instructions/pdi43

copy discharge instructions

›Eczema herpeticum home care instructions

›Antiviral medication

›Take all antiviral pills exactly as prescribed until the full course is complete

›Do not stop early even if the skin is improving

›Skin care

›Continue your prescribed eczema cream or steroid as instructed

›Gently clean affected skin with mild soap and water twice daily

›Apply prescribed ointments or barrier creams to areas of broken skin

›Activity and hygiene

›Stay home from school, sports, or daycare until all lesions are fully crusted over

›Do not share towels, clothing, or bedding with others

›Wash hands frequently to avoid spreading infection

›Hydration and rest

›Drink plenty of fluids especially if fever is present

›Rest and avoid strenuous activity until fever resolves

›Return to emergency department immediately for

›Eye symptoms

›Eye pain, redness, or vision changes

›Discharge from eyes or sensitivity to light

›Neurological symptoms

›New confusion, severe headache, or seizure

›Difficulty waking from sleep or unusual drowsiness

›Infection worsening

›Rash spreading rapidly despite antiviral medication

›Increasing redness, warmth, swelling, or pus suggesting bacterial infection

›Systemic deterioration

›High fever (greater than 39 C) not responding to acetaminophen or ibuprofen

12References/r26

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

›Tzanck smear role and limitations

›Coding and classification standards

›ICD-10 B00.0 eczema herpeticum (Kaposi varicelliform eruption)

›ICD-10 B00.4 herpes simplex encephalitis

›ICD-10 B00.7 disseminated herpes simplex disease

›SNOMED CT: Kaposi varicelliform eruption (disorder)

›Concept maps to EH in clinical coding systems

Learn More: Eczema Herpeticum→

Comprehensive Clinical Review

Structured, evidence-informed, long-form analysis for deeper understanding.

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.