Eczema herpeticum is a viral skin infection that causes fever and vesicles (small fluid-filled sacs on the skin) that erupt into itchy blisters. This infection, most commonly caused by the herpes simplex virus (HSV), appears as a complication of preexisting skin conditions. Eczema herpeticum usually arises from atopic dermatitis (AD) — the most common type of eczema that is frequently referred to as eczema.

Eczema herpeticum is a disseminated infection. This means it can spread (disseminate) from the primary site of infection to other parts of the body. Eczema herpeticum can be severe and, if left untreated, may lead to potentially fatal bacterial superinfection and bacteremia (bacteria in the bloodstream).

What Causes Eczema Herpeticum?

Eczema herpeticum is usually caused by HSV type 1 or 2 (HSV-1 or HSV-2). HSV-1 causes most cold sores, and HSV-2 causes genital herpes. This virus is contracted through person-to-person contact with someone infected with HSV.

Atopic dermatitis impairs the skin’s protective abilities so pathogens can more easily penetrate the skin due to the broken skin barrier. Because of this, AD is often complicated by recurrent viral and bacterial skin infections. People with AD have been found to have reduced immunity to herpes infections and be more susceptible to eczema herpeticum.

Eczema herpeticum is most common among children and infants with atopic dermatitis, although it can affect people of all ages.

What Is the Prevalence of Eczema Herpeticum?

Atopic dermatitis, the biggest risk factor for eczema herpeticum, is the most common type of chronic eczema in the world. It affects between 10 percent and 20 percent of children in developed countries and approximately 10 percent of adults in the United States.

HSV is a very common infection. Approximately 20 percent of children and more than 60 percent of adults test positive for the virus. Eczema herpeticum, however, is rare, affecting less than three percent of people with AD. This suggests that eczema herpeticum results from many factors — not just environmental exposure to HSV.

What Are the Symptoms of Eczema Herpeticum?

The symptoms of eczema herpeticum appear roughly five to 12 days after coming into contact with a person infected with HSV. These symptoms begin with clusters of itchy, painful blisters.

Eczema herpeticum on the neck (DermNet NZ)

Unlike the common cold sore, which is confined to a small area, eczema herpeticum blisters can spread over large areas of the skin. These blisters can develop on areas of skin that have or have not been previously affected by eczema or other skin conditions. Although it can affect any part of the body, eczema herpeticum is most commonly seen on the face and neck.

The blisters caused by eczema herpeticum may:

• Be itchy and painful
• Contain pus that oozes when broken open
• Be blood-stained, appearing red, purple, or black
• Form lesions that take two to six weeks to heal (in severe cases, long-term small white scars may be present)
• Form erosions of the skin where blisters have popped

New blisters may also have umbilication, or dimple-like central depressions, whereas old blisters may form crusts and sores.

Other symptoms of eczema herpeticum may include:

• Swollen lymph nodes
• Fever and chills
• Generally feeling unwell (malaise)

Secondary bacterial infection in eczema herpeticum may cause impetigo (a highly contagious skin infection most commonly seen in infants and children) and cellulitis (a common but potentially serious bacterial skin infection).

Complications of Eczema Herpeticum

Severe cases of eczema herpeticum may affect other organs, including the brain, eyes, liver, gastrointestinal tract, and lungs. For this reason, you should seek immediate medical care if you experience any symptoms resembling those of eczema herpeticum.

Potential complications of eczema herpeticum include:

• Scarring after blisters have healed
• Herpetic keratitis (infection in the eye cornea), which, if left untreated, can cause blindness
• Organ failure and death, if the virus affects the brain, liver, and lungs
• Secondary bacterial infections that can infect the skin and internal organs

How Is Eczema Herpeticum Diagnosed?

A doctor can usually diagnose eczema herpeticum based on your visible and reported symptoms. If a person with known eczema presents with a sudden onset of painful, clustered blisters, fever, and a general feeling of sickness, it’s usually a sign of the disease.

Eczema herpeticum may sometimes be confused with other skin conditions, such as impetigo, cellulitis, primary varicella (chickenpox) infection, or hand, foot and mouth disease.

To rule out other possible causes of your symptoms, a doctor will perform a differential diagnosis. A culture from the infected skin may be taken for laboratory testing to confirm a diagnosis of eczema herpeticum. A Tzank smear can be done in the office for rapid diagnosis. If the diagnosis is not clear, a skin biopsy can also be done.

Misdiagnosing eczema herpeticum can delay proper treatment and result in serious complications, including herpetic simplex keratitis (an HSV infection of the eye) and death. Receiving a timely, accurate diagnosis and the right treatment for eczema herpeticum is crucial in avoiding potential severe complications.

Treatments for Eczema Herpeticum

Eczema herpeticum is one of the few skin conditions that require urgent medical attention. Prompt treatment is necessary to avoid hospitalization, progression to severe disease, and further complications.

The medications most commonly used to treat eczema herpeticum are Sitavig and Zovirax (acyclovir) and Valtrex (valacyclovir).

Preventive antibiotics may also be administered to people taking medication for eczema herpeticum to prevent superinfection with bacteria like Staphylococcus aureus. These antibiotics include cephalexin, doxycycline, Clindamycin, and Bactrim (trimethoprim/sulfamethoxazole).

According to the National Institutes of Health, treatment for eczema herpeticum is administered as per the following information.

Mild Cases

People with mild cases of eczema herpeticum are treated with oral acyclovir or valacyclovir. Both children and adults are given varying dosages three times a day for seven to 21 days, or until the lesions heal into crusts. Valacyclovir has a more convenient dosing regimen.

Severe and Immunocompromised Cases

People with severe eczema herpeticum or those with compromised immune systems are hospitalized for monitored treatment.

During hospitalization, intravenous (IV) injections of acyclovir are administered every eight hours. The individual is then transitioned to oral acyclovir, once symptoms have improved and their lesions have started to heal into crusts.

While still under professional care, emollients and cool compresses are applied to help relieve the symptoms of eczema herpeticum.

Critical Illness

People with eczema herpeticum in critical condition are hospitalized and may receive IV fluids and electrolytes. Wound care, pain control, and nutritional support are also necessary.

Individuals are advised on how to prevent spreading infection to other parts of the body through frequent hand-washing. This also helps prevent them from infecting others with HSV.

Preventing the Spread of Eczema Herpeticum

The following precautions should be taken to prevent the spread of infection when dealing with eczema herpeticum.

Avoid Skin-to-Skin Contact

The HSV-1 and HSV-2 viruses spread through skin-to-skin contact. If you have symptoms of eczema herpeticum, avoid skin contact with others to prevent the virus from spreading to them.

Similarly, people who don’t have the disease should avoid skin contact with someone who has a cold sore or any other symptoms caused by the herpes simplex virus.

Wash Your Hands Regularly

It’s possible to pick up the virus without knowing it through daily contact with different objects. HSV can live for short amounts of time on doorknobs, furniture, electronic devices, and any other object that you might come into contact with at home or in public.

Washing your hands frequently with soap and warm water can help prevent you from getting the virus.

Avoid Sharing Objects That Touch the Mouth

Kissing, sharing lipstick, eating from the same spoon, drinking from the same glass, and sharing other objects that come into contact with the mouth can promote the spread of the herpes virus.

For People Who Are Hospitalized

At the hospital, certain precautions are taken to prevent spreading the virus, including isolation. Health care providers use face masks and gowns when caring for hospitalized individuals. Individuals are constantly monitored for secondary bacterial superinfection, and systemic antibiotics are administered as required.

Finding Support

MyEczemaTeam is the social network and online support group for people living with all forms of eczema and their loved ones. Here, more than 34,000 people connect to share their stories, offer advice, and learn from each other.

Do you experience eczema herpeticum? How do you deal with it? Join us at MyEczemaTeam today and let members know what it’s like in the comments below, or start a conversation by posting on your Activities page.