Derm Dx: Rash on the Cheek and Scalp - Clinical Advisor

Derm Dx: Rash on the Cheek and Scalp

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A 24-year-old Hispanic man presents for evaluation of an acute-onset rash on his left cheek and scalp. He experienced a slight fever the day prior to the eruption and currently complains of minimal discomfort. Medical history is significant for atopic dermatitis that developed in early childhood. This condition had recently flared, and the patient received an intramuscular injection of triamcinolone 2 weeks ago. Examination revealed multiple papulovesicles of the affected area.

Can you diagnose this condition?

Eczema herpeticum is an uncommon complication of dermatoses caused by an acute and disseminated infection with the herpes simplex virus (HSV). Eczema herpeticum can lead to tissue erosion, superinfection, bacteremia, and death if not properly identified and treated.1 Dissemination of...

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Eczema herpeticum is an uncommon complication of dermatoses caused by an acute and disseminated infection with the herpes simplex virus (HSV). Eczema herpeticum can lead to tissue erosion, superinfection, bacteremia, and death if not properly identified and treated.1 Dissemination of HSV may accompany a flare of atopic dermatitis and is related to impairment of the epidermal layer and immune dysfunction. Other conditions rarely associated with eczema herpeticum include psoriasis, contact dermatitis, burns, and seborrheic dermatitis.2

Clinical presentation of eczema herpeticum often begins with viral prodromal symptoms of fever, malaise, and rash. Progression of rash leads to small, monomorphic, dome-shaped papulovesicles that eventuate in shallow ulcers after rupturing.3,4 Crusted, impetigo-like lesions are not uncommon due to concurrent infection with other skin pathogens such as Staphylococcus aureus.

Diagnosis is usually made clinically; viral culture, Tzanck smear for multinucleated giant cells, and direct fluorescence antigen testing can be utilized for confirmation.4

Management of eczema herpeticum consists of prompt identification and initiation of antiviral therapy. Immunocompromised patients and those with severe disease may require hospital admission and intravenous antiviral medication. Antibacterial therapies may also be indicated due to secondary infection.4 Recurrence of eczema herpeticum is more commonly seen in patients who experienced a primary episode before one year of age.1

Kevin Anderson is a physician assistant student at Arcadia University. Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, as well as an associate professor of medicine at Commonwealth Medical College and a clinical instructor of dermatology at Arcadia University and Kings College.

References

  1. Blanter M1, Vickers J, Russo M, Safai B. Eczema herpeticum: would you know it if you saw it? Pediatr Emerg Care. 2015;31(8):586-588.
  2. Wollenberg A, Wetzel S, Burgdorf WH, Haas J. Viral infections in atopic dermatitis: pathogenic aspects and clinical management. J Allergy Clin Immunol. 2003;112(4):667-674.
  3. Studdiford JS, Valko GP, Belin LJ, Stonehouse AR. Eczema herpeticum: making the diagnosis in the emergency department [published online June 27, 2008]. J Emerg Med. doi: 10.1016/j.jemermed.2007.11.049
  4. Liaw FY, Huang CF, Hsueh JT, Chiang CP. Eczema herpeticum: a medical emergency. Can Fam Physician. 2012;58(12):1358-1361. 
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