Test Your Knowledge : Ten Questions about Eczema Herpeticum

Question 3. Which one of the following statements best refl ects the association between eczema herpeticum and other skin diseases? Eczema herpeticum most commonly occurs in patients with pre-existing atopic dermatitis Eczema herpeticum only occurs in patients with preexisting atopic dermatitis Eczema herpeticum can occur in a variety of skin diseases, all of which are either allergic or autoimmune Question 4. Which one of the following best refl ects current knowledge of eczema vaccinatum occurring after smallpox vaccination? Following the recent smallpox vaccination campaign in the United States, there have been a large number of cases of eczema vaccinatum Eczema vaccinatum is only a risk in those who are vaccinated The US Centers for Disease Control and Prevention (CDC) states that a person who has a past history of atopic dermatitis but who has no active disease can safely receive smallpox vaccination The CDC cautions that any history of atopic dermatitis or eczema is a contraindication to receiving smallpox vaccination


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Online Quiz Question 1.Based on the evidence to date, which of the following describes the incidence of eczema herpeticum?
Question 7. Which one of the following best refl ects current knowledge of antiviral therapy for eczema herpeticum?
There have been no randomized controlled trials of antiviral therapy for eczema herpeticum Intravenous therapy is indicated for all patients, regardless of disease severity Oral therapy has been shown to be effective, but is generally used only for mild cases Question 8. Which of the following best refl ects current practice when it comes to using aciclovir to treat pregnant women with eczema herpeticum?
Since there is no evidence for a teratogenic effect, there are no concerns about giving the drug during pregnancy Aciclovir is teratogenic and should never be given to pregnant women with eczema herpeticum Although the issue of whether to give the drug during pregnancy is still controversial, women are often given the drug because eczema herpeticum in pregnancy can cause intrauterine infection in 50% of cases Question 9. Which of the following best refl ects the current management approach to eczema herpeticum?
Since the disease is viral, there is no place for antibiotics Antibiotics are often needed because secondary bacterial sepsis is common, usually involving anaerobic bacteria Antibiotics are often needed because bacterial sepsis is common, usually involving Staphylococcus aureus or group A beta-hemolytic streptococci

Question 10. Which of the following most accurately describes the association between atopic dermatitis and viral skin infections?
Eczema herpeticum is the only viral infection associated with atopic dermatitis Patients with atopic dermatitis are at risk of a variety of viral infections, many of which can become disseminated eruptions Patients with atopic dermatitis are at risk of a variety of viral infections, but eczema herpeticum is the only one that becomes a disseminated eruption

Answer 1. The incidence is probably increasing
There has been little research on the incidence of eczema herpeticum, but one study from the Department of Dermatology at the University of Mainz, Germany, found a sharp rise in incidence in the period from 1969 to 1986 [1].From 1969 through 1981, 13 cases were registered, whereas for the years 1982 to 1986, the number of cases was 62.It is unclear whether the increase in registered cases refl ected a genuine change in the epidemiology of atopic eczema/ herpes simplex or was due to increased reporting.

Answer 2. Earlier onset of atopic dermatitis
Two retrospective analyses-one of 75 cases and the other of 100 cases-found two predisposing factors [1,2]: early onset of atopic dermatitis and a high total serum IgE level.In these studies, topical corticosteroids did not predispose to eczema herpeticum.In one of the studies, 75% of those who developed eczema herpeticum had not received corticosteroids in the four weeks preceding its onset-the authors concluded that most cases of eczema herpeticum occurred in patients with inadequately treated atopic dermatitis [2].

Answer 3. Eczema herpeticum most commonly occurs in patients with pre-existing atopic dermatitis
Eczema herpeticum most commonly occurs in patients with pre-existing atopic dermatitis.In one retrospective analysis of 100 cases of eczema herpeticum, most occurred in patients with untreated atopic dermatitis [1].However, eczema herpeticum can be associated with other skin conditions with a wide range of etiologies-not just allergic or autoimmunesuch as seborrheic dermatitis [2], pemphigus [3], second degree burns [4], and conditions due to sun exposure [5].

Answer 4. The CDC cautions that any history of atopic dermatitis or eczema is a contraindication to receiving smallpox vaccination
There have been no cases so far of eczema vaccinatum following the recent smallpox vaccination program in the US, though if the program is extended there may be new cases.There has been a case of eczema vaccinatum following smallpox vaccination in Israel [1].Eczema vaccinatum occurs in the setting of a compromised epidermal barrier.It should be suspected in any patient with a history of atopic dermatitis who has typical clinical features and either has been vaccinated against smallpox or has had contact with an individual who has been vaccinated 5-20 days prior to presentation [2].To reduce the risk of inadvertent inoculation of a patient with atopic dermatitis, the CDC cautions that any history of atopic dermatitis or eczema is a contraindication to receiving smallpox vaccine [3].The CDC has a freely available Internet-based training module on smallpox for physicians at http:⁄⁄www.bt.cdc.gov/agent/smallpox/training/index.asp.

Answer 6. Dome-shaped vesicles, which dry out and form crusts
Patients with eczema herpeticum typically present with a disseminated monomorphic eruption of dome-shaped vesicles, most often on the head, neck, and trunk.Within two weeks, the vesicles usually dry out and form crusted papules [1].

Answer 7. Oral therapy has been shown to be effective, but is generally used only for mild cases
There has been one multi-center, controlled trial of oral aciclovir for eczema herpeticum, involving 69 patients who were randomized to aciclovir (200 mg fi ve times per day for fi ve days) or placebo.Clinical effi cacy was assessed using a numerical rating scale for various parameters, such as lesion stage, pain, and general improvement.The drug was found to have a signifi cantly greater clinical effi cacy than placebo [1].The cornerstone of treatment for eczema herpeticum is prompt systemic antiviral therapy, such as a seven-day course of intravenous aciclovir (5-10 mg/kg three times per day), which may be prolonged according to clinical response [2,3].As discussed above, oral therapy has been shown to be effective, though it has a lower bioavailability than intravenous therapy and its use is generally restricted to less severe cases [2,3].

Answer 8. Although the issue of whether to give the drug during pregnancy is still controversial, women are often given the drug because eczema herpeticum in pregnancy can cause intrauterine infection in 50% of cases
It is standard practice to give aciclovir to pregnant women with eczema herpeticum (5-10 mg/kg intravenously three times per day for at least seven days) because there is a 50% risk of intrauterine infection (usually during the fi rst 20 weeks) [1].Intrauterine infection can cause spontaneous abortions and birth defects [1].While there is no evidence of a teratogenic effect, there are still concerns about giving the drug during pregnancy because no large, well-controlled studies have been done [1].

Answer 9. Antibiotics are often needed because bacterial sepsis is common, usually involving Staphylococcus aureus or group A beta-hemolytic streptococci
Patients with eczema herpeticum often require antibiotic therapy because they commonly get secondary bacterial infection with S. Aureus or group A beta-hemolytic streptococci [1,2].

Answer 10. Patients with atopic dermatitis are at risk of a variety of viral infections, many of which can become disseminated eruptions
Patients with atopic dermatitis are at risk of many different viral skin infections, all of which can become disseminated, including the following: eczema herpeticum (usually due to herpes simplex virus type 1), eczema molluscatum (due to molluscum contagiosum virus), and eczema vaccinatum (following smallpox vaccination) [1].