Sudden eruption of pruritus and pain

The patient is empirically diagnosed with AD and eczema herpeticum. A Tzanck smear is done and is positive for multinucleate giant cells with nuclear molding and ballooning degeneration of the keratinocytes. 

Eczema herpeticum, or Kaposi varicelliform eruption, is a rare but potentially life-threatening complication of AD. It is an extensive cutaneous vesicular eruption that arises from pre-existing skin disease — in most cases, AD — and is caused by disseminated cutaneous viral infection, usually with the herpes simplex virus (HSV). The virus can infect the epidermis because of the skin barrier defects that are inherently associated with AD. Patients with AD and filaggrin gene null mutations may have an increased risk for eczema herpeticum. 

Eczema herpeticum is associated with significant morbidity and is considered a medical emergency. Early diagnosis and treatment is essential to prevent or minimize complications. Complications of eczema herpeticum can include keratoconjunctivitis, which may lead to vision loss, as well as multiorgan involvement with meningoencephalitis and/or septic shock. 

Eczema herpeticum occurs on areas of preexisting AD (or other skin disease) and presents as small, dome-shaped, grouped papule-vesicles on an erythematous base. When these vesicles rupture, punched-out ulcers are formed. It is seen most often on the face, neck, and upper trunk. Fever, malaise, and lymphadenopathies may also be present. 

Among patients with severe or poorly controlled AD, even the classic presentation of eczema herpeticum can be challenging to recognize. Clinicians should maintain a high index of suspicion for this complication in any patient with AD who presents with an acute pruritic and painful rash, including pediatric patients, who have the highest risk for the development of eczema herpeticum.

Viral PCR on vesicle fluid can confirm the diagnosis of eczema herpeticum and determine the type of HSV with high sensitivity and specificity. If unavailable, a Tzanck smear of an opened vesicle or erosion can confirm an HSV infection and provide rapid diagnosis, but its sensitivity and specificity can vary. Direct fluorescence antigen testing is a fast and inexpensive method for detecting an HSV antigen and distinguishing between HSV-1 and HSV-2 infections. Bacterial cultures should be performed when there is a concern for impetiginization. A skin biopsy may be indicated in cases involving atypical presentation. 

Immediate treatment with oral acyclovir should be initiated for any patient with eczema herpeticum; patients with severe disease or who are immunocompromised may require hospitalization for administration of systemic antivirals. Because secondary bacterial infections are common, prophylactic antibiotics (eg, cephalexin, clindamycin, doxycycline, or trimethoprim-sulfamethoxazole) may also be indicated. Finally, consultation with an ophthalmologist is indicated when herpes keratitis is suspected. 

Richard Vinson, MD, President, Mountain View Dermatology, El Paso, Texas.

Richard Vinson, MD, has disclosed no relevant financial relationships.

The patient is empirically diagnosed with AD and eczema herpeticum. A Tzanck smear is done and is positive for multinucleate giant cells with nuclear molding and ballooning degeneration of the keratinocytes. 

Eczema herpeticum, or Kaposi varicelliform eruption, is a rare but potentially life-threatening complication of AD. It is an extensive cutaneous vesicular eruption that arises from pre-existing skin disease — in most cases, AD — and is caused by disseminated cutaneous viral infection, usually with the herpes simplex virus (HSV). The virus can infect the epidermis because of the skin barrier defects that are inherently associated with AD. Patients with AD and filaggrin gene null mutations may have an increased risk for eczema herpeticum. 

Eczema herpeticum is associated with significant morbidity and is considered a medical emergency. Early diagnosis and treatment is essential to prevent or minimize complications. Complications of eczema herpeticum can include keratoconjunctivitis, which may lead to vision loss, as well as multiorgan involvement with meningoencephalitis and/or septic shock. 

Eczema herpeticum occurs on areas of preexisting AD (or other skin disease) and presents as small, dome-shaped, grouped papule-vesicles on an erythematous base. When these vesicles rupture, punched-out ulcers are formed. It is seen most often on the face, neck, and upper trunk. Fever, malaise, and lymphadenopathies may also be present. 

Among patients with severe or poorly controlled AD, even the classic presentation of eczema herpeticum can be challenging to recognize. Clinicians should maintain a high index of suspicion for this complication in any patient with AD who presents with an acute pruritic and painful rash, including pediatric patients, who have the highest risk for the development of eczema herpeticum.

Viral PCR on vesicle fluid can confirm the diagnosis of eczema herpeticum and determine the type of HSV with high sensitivity and specificity. If unavailable, a Tzanck smear of an opened vesicle or erosion can confirm an HSV infection and provide rapid diagnosis, but its sensitivity and specificity can vary. Direct fluorescence antigen testing is a fast and inexpensive method for detecting an HSV antigen and distinguishing between HSV-1 and HSV-2 infections. Bacterial cultures should be performed when there is a concern for impetiginization. A skin biopsy may be indicated in cases involving atypical presentation. 

Immediate treatment with oral acyclovir should be initiated for any patient with eczema herpeticum; patients with severe disease or who are immunocompromised may require hospitalization for administration of systemic antivirals. Because secondary bacterial infections are common, prophylactic antibiotics (eg, cephalexin, clindamycin, doxycycline, or trimethoprim-sulfamethoxazole) may also be indicated. Finally, consultation with an ophthalmologist is indicated when herpes keratitis is suspected. 

Richard Vinson, MD, President, Mountain View Dermatology, El Paso, Texas.

Richard Vinson, MD, has disclosed no relevant financial relationships.

The patient is empirically diagnosed with AD and eczema herpeticum. A Tzanck smear is done and is positive for multinucleate giant cells with nuclear molding and ballooning degeneration of the keratinocytes. 

Eczema herpeticum, or Kaposi varicelliform eruption, is a rare but potentially life-threatening complication of AD. It is an extensive cutaneous vesicular eruption that arises from pre-existing skin disease — in most cases, AD — and is caused by disseminated cutaneous viral infection, usually with the herpes simplex virus (HSV). The virus can infect the epidermis because of the skin barrier defects that are inherently associated with AD. Patients with AD and filaggrin gene null mutations may have an increased risk for eczema herpeticum. 

Eczema herpeticum is associated with significant morbidity and is considered a medical emergency. Early diagnosis and treatment is essential to prevent or minimize complications. Complications of eczema herpeticum can include keratoconjunctivitis, which may lead to vision loss, as well as multiorgan involvement with meningoencephalitis and/or septic shock. 

Eczema herpeticum occurs on areas of preexisting AD (or other skin disease) and presents as small, dome-shaped, grouped papule-vesicles on an erythematous base. When these vesicles rupture, punched-out ulcers are formed. It is seen most often on the face, neck, and upper trunk. Fever, malaise, and lymphadenopathies may also be present. 

Among patients with severe or poorly controlled AD, even the classic presentation of eczema herpeticum can be challenging to recognize. Clinicians should maintain a high index of suspicion for this complication in any patient with AD who presents with an acute pruritic and painful rash, including pediatric patients, who have the highest risk for the development of eczema herpeticum.

Viral PCR on vesicle fluid can confirm the diagnosis of eczema herpeticum and determine the type of HSV with high sensitivity and specificity. If unavailable, a Tzanck smear of an opened vesicle or erosion can confirm an HSV infection and provide rapid diagnosis, but its sensitivity and specificity can vary. Direct fluorescence antigen testing is a fast and inexpensive method for detecting an HSV antigen and distinguishing between HSV-1 and HSV-2 infections. Bacterial cultures should be performed when there is a concern for impetiginization. A skin biopsy may be indicated in cases involving atypical presentation. 

Immediate treatment with oral acyclovir should be initiated for any patient with eczema herpeticum; patients with severe disease or who are immunocompromised may require hospitalization for administration of systemic antivirals. Because secondary bacterial infections are common, prophylactic antibiotics (eg, cephalexin, clindamycin, doxycycline, or trimethoprim-sulfamethoxazole) may also be indicated. Finally, consultation with an ophthalmologist is indicated when herpes keratitis is suspected. 

Richard Vinson, MD, President, Mountain View Dermatology, El Paso, Texas.

Richard Vinson, MD, has disclosed no relevant financial relationships.