Severe rash after dermatitis
Treatment: systemic antivirals, antibiotics
Systemic antiviral medications are the mainstay of treatment for eczema herpeticum. Before the advent of acyclovir, the mortality rate of eczema herpeticum was 75%.2
The nucleoside analogs, which work by inhibiting viral DNA replication, are the most commonly used antiviral agents. Most of the studies on the treatment of eczema herpeticum have been on acyclovir; a 7-day course of IV therapy is typical. Alternatives such as valacyclovir have also been shown to be effective and have better oral bioavailability. Topical antivirals are often used for prophylaxis of keratoconjunctivitis if lesions are found around eyelids.
Antibiotics are often necessary to treat bacterial superinfection. Topical or systemic corticosteroids are not generally recommended and may worsen disease by attenuating the immune response.
Patient follow-up
This patient was initially treated with levofloxacin (Levaquin) for a presumed diagnosis of dermatitis with bacterial superinfection. Vancomycin was added on hospital day 2 when the rash was not improving. Due to a high suspicion for eczema herpeticum, a direct fluorescent antibody test sent for herpes, When the test results came back positive, the patient was started on intravenous acyclovir. A HSV PCR also had positive results. An ophthalmology specialist found no evidence for herpes keratoconjunctivitis and made no further recommendations.
The patient responded to the treatment and was discharged on hospital day 5. She was given a 10-day course of valacyclovir and a 21-day course of levofloxacin to complete at home. The patient fully recovered from the acute infections with some residual scarring.
