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Editor,—We present a case of eczema herpeticum to highlight that herpes simplex can cause generalised infection in atopic individuals and should be considered in the differential diagnosis.
A 19 year old man presented with 2 day history of extensive painful pustular eruptions of the hands, forearms, and chest. He also felt unwell and had fever. Fingers were stiff and could not be fully extended. He was seen in the local accident and emergency department and prescribed flucloxicillin. On direct questioning he admitted that his illness started with painful penile ulcers followed 2 days later by generalised crops of blisters, which then became infected. Ten days before this he had unprotected sexual intercourse with a casual female friend in Ibiza. He had extensive atopic eczema during childhood, which is well controlled now but has been getting hay fever for the past few years.
Examination revealed symmetrical pustular eruptions on the hands, wrist, forearms, lower legs and chest, and a few vesicular eruptions on the hands typical of herpes. He also had multiple superficial penile ulcers. Axillary and inguinal lymph nodes were enlarged. There was also evidence of generalised eczema.
Herpes simplex was isolated from the penile ulcers. Screening for other STIs and HIV was negative. He was treated with aciclovir 200 mg five times a day for 5 days with very good response. Two months later he presented to us with a similar episode that required treatment with aciclovir. Since then he has been seen on two occasions with recurrence in the past year, but the attacks were more localised to his hands and external genitalia (fig 1).
Eczema herpeticum is classically a disseminated herpes simplex infection of the skin occurring in patients with pre-existing active dermatitis. The severity varies from mild transient disease to a fulminating fatal disorder involving the visceral organs.1, 2 The severity appears to be unrelated to the extent of eczematous lesions. Active dermatitis is not necessary for the development of recurrent eczema herpeticum.
Atopic dermatitis typically begins in early infancy, and individuals with this disease frequently develop other atopic manifestations later in life such as hay fever, allergic rhinitis, and bronchial asthma.3 Eczema herpeticum has also been associated with seborrhoeic dermatitis, neurodermatitis, Darier's disease, pemphigus, mycosis fungoides, Wiskott-Aldrich disease, congenital ichthyosiform erythroderma,4, 5 and second degree burns.6
The presentation in our patient is fairly typical, lesions appearing in crops initially as tiny vesicles passing through pustular and crusted phases associated with systemic symptoms. This condition is often misdiagnosed because the lesions are usually scratched and blistering is lost leaving raw punched out areas often with secondary infection. Diagnosis is based on patient history of atopic disease, presence of vesicular lesion, the striking tendency for the lesions to return to the same areas of the skin, and a positive result of viral culture for herpes simplex.
Eczema herpeticum is now being seen with increasing frequency in adults5 and herpes simplex infection should be considered in the differential diagnosis of vesicular skin lesions occurring in atopic patients.