Rita V. E-mail: gro. Sir, A year-old man who was being regularly treated for pemphigus vulgaris since two years presented with complaints of continuous high-grade fever since two days and multiple fluid-filled lesions that appeared initially over the face, and later over the chest, back, and limbs. Cutaneous examination showed multiple umbilicated vesicular lesions a few of them coalesced over the face with severe facial edema [ Figure 1 ], chest [ Figure 2 ], trunk, and all four limbs along with multiple punched out erosive lesions and a few crusted lesions. Old crusted lesions of pemphigus were present over the scalp with patchy hair loss.
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Management 3. The indicated treatment is administration of acyclovir There are no clear guidelines about which patients should be hospitalized to receive intravenous acyclovir versus managed as outpatients with less-bioavailable oral acyclovir 5. Regardless, patients with severe disease and immunocompromised patients should be admitted to receive systemic antiviral therapy  .
If bacterial superinfection is suspected, treatment should include antibiotics . These treatments should be continued for one to two weeks until symptoms resolve . For HSV conjunctivitis, three options for management are ganciclovir 0. Treatment should last one to two weeks, and reevaluation is recommended if the conjunctivitis does not resolve after this period .
For herpes keratitis, options for management include ganciclovir 0. If compliance with these treatments is an issue, for example in pediatric patients, intravenous or oral antiviral agents e. The use of topical steroids is contraindicated and should be quickly tapered off  .
Adjunctive debridement of infected corneal epithelial cells at the slit lamp can be done in addition to antiviral therapy. If epithelial defects do not resolve after 7 to 14 days, topical antiviral therapy should be withdrawn and preservative-free artificial tears or an antibiotic ointment should be used four to eight times per day with close monitoring and follow-up over several days. A lack of resolution after this time should also lead to investigation of possible bacterial coinfection, Acanthomoeba keratitis, noncompliance with therapy, and topical antiviral toxicity.
Regarding the latter, it has been suggested that topical ganciclovir gel carries a lower risk of corneal toxicity than trifluridine . Treatment of corneal stromal disease depends on disease severity. For mild cases of disciform non-necrotizing keratitis, antiviral prophylaxis and cycloplegic therapy are recommended. Cycloplegic therapy is similarly recommended for moderate to severe cases, in addition to a topical steroid do not initiate topical steroid therapy while an active epithelial lesion is present!
If epithelial defects are present, topical antibiotics may be used adjunctively; if intraocular pressure is elevated, aqueous suppressants may be used, avoiding prostaglandin analogues. Necrotizing interstitial keratitis is managed as severe disciform keratitis. Patients with necrotizing interstitial keratitis require daily follow-up or admission to monitor for perforation. If the cornea perforates, tissue adhesive or corneal transplantation may be necessary .
Patients being treated for ocular HSV should follow up for repeat examination two to seven days after initiating treatment, and again every one to two weeks depending on examination findings. The size of any epithelial defect or ulcer, depth of corneal involvement, corneal thickness, intraocular pressure, and anterior chamber reaction should all be evaluated .
A common complication of EH is bacterial superinfection, with the most common organisms being Staphylococcus aureus, Streptococcus pyogenes, and Pseudomonas aeruginosa .
As discussed above, ocular HSV infection is among the most feared complications of EH, and corneal transplant may be indicated in cases of postherpetic scarring that significantly affects vision   .
Indian Dermatol Online J. Predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of cases. J Am Acad Dermatol. Epidemiology of Eczema Herpeticum in Hospitalized U. Children: Analysis of a Nationwide Cohort. J Invest Dermatol. Epub Sep J Am Acad Dermatol, 53 , pp. Eczema herpeticum in children: clinical features and factors predictive of hospitalization. J Pediatr. Epub May 9.
Herpes simplex infections in atopic eczema. Arch Dis Child, 60 , pp. Clin Rev Allergy Immunol. Treatment of ocular disease in eczema herpeticum. Am J Ophthalmol. J Clin Med. J Invest Dermatol, , pp. Eczema herpeticum. Clinical and laboratory features. Clin Pediatr Phila , 27 , pp. Infectious complications in atopic dermatitis. Immunol Allergy Clin N Am, 37 , pp. Kaposi varicelliform eruption eczema herpeticum. Dermatol Online J, 14 , p. Phenotype of atopic dermatitis subjects with a history of eczema herpeticum.
J Allergy Clin Immunol. Kaposi varicelliform eruption in patients with Darier disease: a year retrospective study. Epub Jan Exp Clin Transplant. Kaposi Varicelliform Eruption. In: StatPearls [Internet]. A corneal dendritic lesion with a skin eruption: eczema herpeticum, an important differential diagnosis. BMJ Case Rep. Eczema Herpeticum. J Emerg Med. N Engl J Med. Arch Dermatol. Disseminated herpes simplex virus: a case of eczema herpeticum causing viral encephalitis.
J R Coll Physicians Edinb. Localized eczema herpeticum with unilateral ocular involvement. Acta Dermatovenerol Alp Pannonica Adriat. Jpn J Ophthalmol. Epub Apr Br J Dermatol Syph. Bilateral corneal geographic ulcers in a patient with eczema herpeticum. Kaohsiung J Med Sci. Philadelphia: Wolters Kluwer, Eczema herpeticum: a medical emergency.
Can Fam Physician. Herpeticum-like rash in a child with atopic dermatitis: early clinical suspicion is valuable. Sudan J Paediatr.
E-mail: moc. This article has been cited by other articles in PMC. It concomitantly occurs with pre-existing skin conditions, mostly atopic dermatitis, so it is predominately found in children. We present a case series that includes four adults, familial cases, and previously healthy patients. We also highlight clinical features, associations and therapeutic options. Other viruses such as Coxsackie A 16, vaccinia,[ 1 ] and varicella zoster[ 2 ] have also been implicated in its pathogenesis.
Kaposi's varicelliform eruption: A case series
Any recurrences of EH, however, should prompt consideration of prophylactic therapy Optimal Therapeutic Approach for this Disease If EH is suspected, early empiric treatment should be initiated immediately. For pediatric patients, initial intravenous therapy is the standard of care but may be transitioned to oral therapy once stable. Oral therapy may be considered in older pediatric patients with less severe and more localized disease. For Immunocompromised patients, initial intravenous therapy is the standard of care but may be transitioned to oral therapy once stable.