Eczema herpeticum

Dermatology

Clinicals - History

Fact Explanation
Clusters of itchy and/or painful blisters in areas of pre-existing skin disease. Found mostly on face and neck, they may be red/purple or black in colour. Disseminated, distinctly monomorphic eruption of dome-shaped vesicles which may transform into pustules or erosions are typical findings with eczema herpeticum. They may lead to hemorrhage; this is the reason for its red/purple or black colour. These lesions are caused by HSV1, HSV2 or rarely coxsackie A 16 or vaccinia virus. Disruption of epidermal barrier and immunosuppression are risk factors. Clusters of itchy and/or painful blisters in areas of pre-existing skin disease. Found mostly on face and neck, they may be red/purple or black in colour.
Disseminated, distinctly monomorphic eruption of dome-shaped vesicles which may transform into pustules or erosions are typical findings with eczema herpeticum. They may lead to hemorrhage; this is the reason for its red/purple or black colour. These lesions are caused by HSV1, HSV2 or rarely coxsackie A 16 or vaccinia virus. Disruption of epidermal barrier and immunosuppression are risk factors.
Flu-like symptoms including fever, malaise and chills Normal response of the body to infection. Flu-like symptoms including fever, malaise and chills
Normal response of the body to infection.
History of pre-existing dermatoses such as atopic dermatitis, psoriasis, eczema, irritant contact dermatitis, seborrheic dermatitis, pemphigus vulgaris, bullous pemphigoid, mycosis fungoides, ichthyosis vulgaris, Darier's disease, cutaneous T-cell lymphoma, Wiskott-Aldrich syndrome and thermal burns etc. Skin is at high risk of infection by viruses and bacteria owing to the disruption of epidermal barrier function(2). Patients with some features of atopic dermatitis such as early onset atopic dermatitis, head and neck atopic dermatitis, or large body surface area involvement have a higher risk of eczema herpeticum. History of pre-existing dermatoses such as atopic dermatitis, psoriasis, eczema, irritant contact dermatitis, seborrheic dermatitis, pemphigus vulgaris, bullous pemphigoid, mycosis fungoides, ichthyosis vulgaris, Darier's disease, cutaneous T-cell lymphoma, Wiskott-Aldrich syndrome and thermal burns etc.
Skin is at high risk of infection by viruses and bacteria owing to the disruption of epidermal barrier function(2). Patients with some features of atopic dermatitis such as early onset atopic dermatitis, head and neck atopic dermatitis, or large body surface area involvement have a higher risk of eczema herpeticum.
Photophobia, blurred vision, redness and tearing of the eye and sometimes but not always blisters around the eye/eye lid. If viral infection has spread to the eye causing herpetic keratitis. This is an ophthalmological emergency. Photophobia, blurred vision, redness and tearing of the eye and sometimes but not always blisters around the eye/eye lid.
If viral infection has spread to the eye causing herpetic keratitis. This is an ophthalmological emergency.
Previous history of eczema herpeticum or other HSV infection. Because recurrence could occur with eczema herpeticum. Viral infection is believed to occur as a result of auto-inoculation in a host with latent infection or may also be from contact with an infected individual. Previous history of eczema herpeticum or other HSV infection.
Because recurrence could occur with eczema herpeticum. Viral infection is believed to occur as a result of auto-inoculation in a host with latent infection or may also be from contact with an infected individual.

Clinicals - Examination

Fact Explanation
Typical rash The skin might begin with erythematous changes presenting as small, monomorphic papulovesicles that are domed shaped. They may rupture to form small punched out ulcers overlying an erythematous base. They may coalesce to form denuded areas that are prone to secondary bacterial colonization. Most often found on the face, neck and upper trunk. Typical rash
The skin might begin with erythematous changes presenting as small, monomorphic papulovesicles that are domed shaped. They may rupture to form small punched out ulcers overlying an erythematous base. They may coalesce to form denuded areas that are prone to secondary bacterial colonization. Most often found on the face, neck and upper trunk.
Fever HSV stimulate phagocytes to produce endogenous pyrogens such as IL-1 , IL-6 , TNF alpha and they cause an elevation in the "set point" for normal body temperature., in the hypothalamus. The body temperature rises until it reaches the set point by shivering, piloerection and vasoconstriction resulting in fever. Fever
HSV stimulate phagocytes to produce endogenous pyrogens such as IL-1 , IL-6 , TNF alpha and they cause an elevation in the "set point" for normal body temperature., in the hypothalamus. The body temperature rises until it reaches the set point by shivering, piloerection and vasoconstriction resulting in fever.
Lymphadenopathy HSV enters lymphatic vessels and gets filtered through lymph nodes. Cells within lymph nodes proliferate in response to antigenic stimuli by the virus which causes lymph nodes to enlarge. Lymphadenopathy
HSV enters lymphatic vessels and gets filtered through lymph nodes. Cells within lymph nodes proliferate in response to antigenic stimuli by the virus which causes lymph nodes to enlarge.

Investigations - Diagnosis

Fact Explanation
Diagnosis is mainly clinical Due to its characteristic appearance occurring together with fever. Diagnosis is mainly clinical
Due to its characteristic appearance occurring together with fever.
Tznack test An easy and quick bedside test. Multinucleated giant cells with acantholytic balloon cells confirm a virus infection but not virus specific. Provides a rapid diagnosis. Tznack test
An easy and quick bedside test. Multinucleated giant cells with acantholytic balloon cells confirm a virus infection but not virus specific. Provides a rapid diagnosis.
Direct florescent antibody testing A fluorescently tagged antibody can detect an HSV antigen and distinguished between HSV-1 and HSV-2 infections. Results are available in a few hours. Direct florescent antibody testing
A fluorescently tagged antibody can detect an HSV antigen and distinguished between HSV-1 and HSV-2 infections. Results are available in a few hours.
Viral culture Culture taken from a fresh vesicle is sensitive or specific for HSV infection, but takes at least 48 hours but if culture is taken from crust, it will be negative. [1,2 Viral culture
Culture taken from a fresh vesicle is sensitive or specific for HSV infection, but takes at least 48 hours but if culture is taken from crust, it will be negative. [1,2
Bacterial culture Due to risk of co-existent bacterial infection Bacterial culture
Due to risk of co-existent bacterial infection
Refer for ophthalmological tests To evaluate ophthalmological involvement by the virus. Refer for ophthalmological tests
To evaluate ophthalmological involvement by the virus.

Management - Supportive

Fact Explanation
Analgesia Analgesics such as acetaminophen or
NSAIDs such as Ibuprofen could be given for pain relief.
Analgesia
Analgesics such as acetaminophen or
NSAIDs such as Ibuprofen could be given for pain relief.
Patient education Patients, especially atopic and immunocompromised individuals should be educated on risk factors, typical features and regarding its recurrence to avoid complications and mortality. Patient education
Patients, especially atopic and immunocompromised individuals should be educated on risk factors, typical features and regarding its recurrence to avoid complications and mortality.

Management - Specific

Fact Explanation
Aciclovir/ valacyclovir (IV/Oral administration) Nucleoside analog antiviral agents. They inhibit viral DNA polymerase. Note that their use should not be delayed pending on laboratory tests as it may lead to keratoconjunctivitis with possible stromal scarring and ultimately blindness and as well as viremia and death by multi-organ involvement including meningitis, encephalitis, herpes hepatitis and disseminated intravascular coagulation.
If the disease is severe and for immunocompromised patients, give IV drugs. If less severe disease oral treatment is sufficient. if the infection is chronic and recurrent, acyclovir or valacyclovir should be given as prophylaxis.
Pyrophosphate analog foscarnet have shown some efficacy in treating acyclovir-resistant immunocompromised patients with HSV infection, although its toxicities such as nephrotoxicity and induction of electrolyte disorders limit its use.
Aciclovir/ valacyclovir (IV/Oral administration)
Nucleoside analog antiviral agents. They inhibit viral DNA polymerase. Note that their use should not be delayed pending on laboratory tests as it may lead to keratoconjunctivitis with possible stromal scarring and ultimately blindness and as well as viremia and death by multi-organ involvement including meningitis, encephalitis, herpes hepatitis and disseminated intravascular coagulation.
If the disease is severe and for immunocompromised patients, give IV drugs. If less severe disease oral treatment is sufficient. if the infection is chronic and recurrent, acyclovir or valacyclovir should be given as prophylaxis.
Pyrophosphate analog foscarnet have shown some efficacy in treating acyclovir-resistant immunocompromised patients with HSV infection, although its toxicities such as nephrotoxicity and induction of electrolyte disorders limit its use.
Antibiotic therapy If bacteria are found in culture,these should be initiated. eg: staphylococcus aureus( Cephalexin , clindamycin , doxycycline or trimethoprim-sulphamethoxazole). Antibiotic therapy
If bacteria are found in culture,these should be initiated. eg: staphylococcus aureus( Cephalexin , clindamycin , doxycycline or trimethoprim-sulphamethoxazole).
Topical antibiotic cream like silver sulphadiazine. Given when there's no bacterial infection but for prophylaxis against a possible secondary infection. Topical antibiotic cream like silver sulphadiazine.
Given when there's no bacterial infection but for prophylaxis against a possible secondary infection.
Ophthalmic acyclovir Given if skin around eye is involved to treat ophthalmologic complications. Ophthalmic acyclovir
Given if skin around eye is involved to treat ophthalmologic complications.

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