Eczema herpeticum is a rare and serious skin infection caused by one of the herpes viruses. It causes a blistery, painful skin rash. It most often affects children who have eczema. It is often confused with other skin infections. It should be treated as soon as possible to avoid complications. It can become very serious if not treated quickly enough. Treatment with an antiviral medicine usually works very well.
What is eczema herpeticum?
Eczema herpeticum is a bad skin infection that occurs in people who already have eczema. The herpes virus (the same one that causes cold sores) invades the skin and causes painful red spots. The rash can spread very quickly over the body and needs to be treated quickly.
Usually the virus is caught from somebody who has an infection such as a cold sore. It takes 5-12 days after contact with the infected person for the rash to develop.
Who gets eczema herpeticum?
Eczema herpeticum can happen at any age. However, it is most common in young children who already have eczema. See the separate leaflet called Atopic Eczema. The eczema causes breaks in the skin which allows the virus in. So it can also happen to people who have other causes of skin breaks - for example, burns or other types of skin conditions.
What are the symptoms of eczema herpeticum?
A child or person with eczema herpeticum develops a skin rash which looks like lots of little blisters. These are usually in areas where there has been a skin condition (usually atopic eczema). The spots are usually quite painful. The spots then spread to other areas of skin. Eczema herpeticum can develop on any part of the body but is most common on the face or neck.
The blisters are all around the same size. They are filled with fluid. It may be a clear fluid or a yellowish fluid called pus. They may bleed or ooze or weep. They then become crusted over.
If you have eczema herpeticum, you feel unwell. You may have a high temperature. You may be able to feel lumps called lymph nodes in your neck, armpits or groin. These come up in response to the infection, to help fight it.
How is eczema herpeticum diagnosed?
Eczema herpeticum is often confused with other skin infections. As it starts with just a few small red spots, it is often confused with chickenpox. The key difference to chickenpox here is that eczema herpeticum has lots of tiny red spots very close together, whereas chickenpox often has slightly larger red spots that are a bit further apart.
As eczema herpeticum is often on the face or around the mouth, it is often confused with impetigo (a common skin infection caused by bacteria). The difference is that a child with eczema herpeticum will often be generally unwell, with a fever, whereas with impetigo they don't usually feel ill.
Sometimes the rapid appearance of the red spots of eczema herpeticum is confused with a simple flare-up of eczema. The key difference is that normal eczema is itchy whereas eczema herpeticum is painful.
If you think you or (more likely) your child have eczema herpeticum it is vital that you see a doctor to check the diagnosis: eczema herpeticum needs to be treated correctly and promptly, otherwise it can become very serious.
Hospital specialists may take a small sample (a swab) of the fluid in one of the spots and send it to the laboratory for testing. Specialist tests can show the herpes virus, which confirms the diagnosis. Most general family doctors do not have access to these tests: they are usually only available in hospital.
This photo shows eczema herpeticum in a baby:
Image source: Open-i - see Further reading reference below
This photo shows the typical appearance of eczema herpeticum in a young child:
By Mohammad2018 (Own work) via Wikimedia Commons
How is eczema herpeticum treated?
Eczema herpeticum is considered an emergency. This is because it can spread quickly. So it must be treated correctly and quickly. If you or your child are diagnosed with eczema herpeticum you will normally be sent to hospital that day for advice from a specialist. In children it is quite common to be admitted to hospital while having the first few days of treatment. In adults, particularly if the infection is mild, it may be sufficient to take tablets and be reviewed by your doctor.
It is important not to be tempted to put a steroid cream on the eczema herpeticum. This will probably make it a lot worse. Many people have steroid creams at home, or have used them for their eczema in the past: you shouldn't use them for a painful skin condition unless advised by your doctor.
Antiviral medicine such as aciclovir is usually very successful for treating eczema herpeticum. It may be given as a liquid or a tablet. For people who are too unwell to take it as a liquid or a tablet, it can be given by a drip (intravenously).
Sometimes an antibiotic may be needed as well. This is because the damage to the skin makes you more likely to become infected by the bacteria normally harmlessly present on the skin as well. This is called a secondary bacterial infection.
Is eczema herpeticum infectious?
Herpes is a very infectious (contagious) virus: you can easily catch it by touching the skin of someone with herpes. For example, if you kiss someone who has a cold sore, there is a high chance you will get a cold sore too. With eczema herpeticum, if you have damaged skin from eczema and you touch the eczema herpeticum there is a reasonable chance you will develop the infection too. This is particularly so if your eczema is inflamed or the skin is very broken.
If your child is hospitalised with eczema herpeticum you will probably have to wear gloves and an apron when you visit them. Elderly people or anyone who is unwell or frail will be advised not to visit them in hospital.
So if you or your child have eczema herpeticum it would be sensible to avoid contact with:
- Children with atopic eczema.
- People who have problems with their immune systems (immunosuppression). This would include people with AIDS, people who have recently had chemotherapy or people who are on steroid medication.
- Newborn babies.
What is the outlook for eczema herpeticum?
As long as eczema herpeticum is treated quickly and with the right antiviral medicine, the outlook (prognosis) is very good. The spots usually heal up and go away in 2-6 weeks. If it is not treated quickly, however, it can spread rapidly and may have complications. It can cause damage to eyesight; there may be secondary infections with other germs such as bacteria; in people whose immune systems are not working well, it may occasionally cause death. This is because it may cause damage to other organs such as the brain, liver or lungs if it spreads.
Usually eczema herpeticum is cured by the antiviral medication. Sometimes eczema herpeticum can come back and need to be treated again.
Further reading and references
Eczema herpeticum; DermNet NZ
Liaw FY, Huang CF, Hsueh JT, et al; Eczema herpeticum: a medical emergency. Can Fam Physician. 2012 Dec58(12):1358-61.
Good NEJM case report with photos of eczema herpeticum; New England Journal of Medicine
Siegfried EC, Hebert AA; Diagnosis of Atopic Dermatitis: Mimics, Overlaps, and Complications. J Clin Med. 2015 May 64(5):884-917. doi: 10.3390/jcm4050884.