Clinical Challenge: 'Punched Out' Erosions on the Face and Neck - MPR

Clinical Challenge: ‘Punched Out’ Erosions on the Face and Neck

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A patient aged 8 years presents with her mother. During the previous 24 hours she developed erosions with a “punched out” appearance on her face and neck. She has a history of atopic dermatitis.

Eczema herpeticum is a disseminated cutaneous herpes simplex infection that occurs as a complication of atopic dermatitis.There is a five to 12 day incubation period after exposure. After the incubation period characteristic umbilicated, vesiculopustular lesions appear. Lesions begin in areas...

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Eczema herpeticum is a disseminated cutaneous herpes simplex infection that occurs as a complication of atopic dermatitis.

There is a five to 12 day incubation period after exposure. After the incubation period characteristic umbilicated, vesiculopustular lesions appear. Lesions begin in areas of dermatitis and subsequently spread.

Eczema herpeticum lesions are pruritic and often become crusted, leading to a punched out appearance. In addition to the skin findings, patients with eczema herpeticum often also present with fever and regional adenopathy.

The punched out lesions help to distinguish eczema herpeticum from impetigo. Impetigo also has fewer systemic symptoms.

In atopic dermatitis, the Th1-mediated immune response is downregulated, whereas Th2 is upregulated. Interleukin 4 production and interferon-gamma levels increase with Th2. This impaired cytotoxic immune response may increase susceptibility to infections. The risk of infection increases because of the broken skin barrier in atopic dermatitis.

Although eczema herpeticum remains the most clinically important cause of disseminated viral infection in atopic dermatitis, eczema molluscatum and eczema vaccinatum are also common infections.

The most common causative organism of eczema herpeticum is herpes simplex virus type 1 (HSV-1). Infection usually occurs in children and can arise after contact with an infected family member or by auto-inoculation.

Eczema herpeticum is a clinical diagnosis but is confirmed using DNA polymerase chain reaction or a Tzanck test displaying multinucleated giant cells. Eczema herpeticum therapy involves treating the HSV-1 infection by giving oral or IV acyclovir, depending on disease severity.

Corticosteroids, although useful in the treatment of atopic dermatitis alone, are not indicated for acute episodes of eczema herpeticum. Cases with periocular involvement necessitate a referral to an ophthalmologist. In this case, the patient was started on IV acyclovir and ophthalmology was consulted given the involvement of her eyelids.

Harina Vin, BS is a medical student at Baylor College of Medicine.

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine also in Houston.

References

  1. James W. (2006) Andrews’ diseases of the skin: clinical dermatology. Philadelphia: Saunders Elsevier.
  2. Fitzpatrick’s dermatology in general medicine. (2012). New York: McGraw-Hill Professional.
  3. Wollenberg A, Wetzel S, Burgdorf W,  Haas J. J. Allergy Clin. Immunol. (2003). “Viral infections in atopic dermatitis: pathogenic aspects and clinical management.”  (112, 667-674)