Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 3 year old male with a history of severe eczema presents for facial rash and hand pain. Mom has been applying aquaphor and vaseline several times a day. This morning, he woke up with a new rash over his face and hands which prompted ED visit. Vitals include BP 103/61, HR 156, Temp 102.9F, RR 30, SpO2 99%. Exam is notable for diffuse, dry skin throughout and findings as below. Lesions spare mucous membranes and palms/soles. Nikolsky sign negative. What’s the diagnosis?

Answer: Eczema Herpeticum

  • Demonstrated by multiple grouped pustules on an erythematous base
  • Typically caused by superinfection of HSV due to a diminished skin barrier from atopic dermatitis
  • Commonly misdiagnosed as impetigo
  • Potentially life-threatening if has multisystem involvement such as HSV keratitis or encephalitis
    • In this case, ophthalmology was consulted to rule out ophthalmologic infection due to extensive rash. Dermatology was consulted for a wound culture which resulted positive for VZV.
  • Treatment includes Acyclovir in addition to gram positive coverage such as Bactrim or Cephalexin


American Academy of Pediatrics: Herpes simplex. In: Kimberlin  DW, Brady  MT, Jackson  MA, Long  SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:432–445.

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