Photo Quiz

Infant with Vesicular Rash

Am Fam Physician. 2010 May 1;81(9):1143-1144.

A seven-month-old girl presented with a rash on her face that had worsened over the previous two days. The patient had a history of eczema and was given hydrocortisone and emollients in the emergency department one week earlier. The rash improved, but then rapidly worsened.

On physical examination, she was non-toxic but had a body temperature of 102.1°F (38.9°C). She was very fussy and scratched at her arms and body. Physical examination also revealed multiple small, elevated vesicles and papules on her face (Figure 1). Many of the vesicles were ruptured or umbilicated, and some coalesced to form crusted plaques. A cluster of vesicles and bullae were noted on her right hand (Figure 2), and scattered ruptured vesicles were noted on her chest and back.

Figure 1.

View Large


Figure 1.


Figure 1.

Figure 2.

View Large


Figure 2.


Figure 2.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Contact dermatitis.

B. Eczema herpeticum.

C. Eczema vaccinatum.

D. Impetigo.

E. Varicella.

Discussion

The answer is B: eczema herpeticum. Eczema herpeticum is characterized by erythematous, ruptured, and crusting vesicles. The rash typically begins on the head or neck as dome-shaped vesicles that subsequently umbilicate, rupture, and often coalesce. The rash usually occurs on areas affected by atopic dermatitis, although it may also affect previously healthy skin.1 Eczema herpeticum is pruritic and may be accompanied by fever, malaise, lymphadenopathy, vomiting, and diarrhea. It is most common in children two to three years of age,2 although it may occur at any age.

Eczema herpeticum is caused by primary herpes simplex virus 1 infection in patients with a disrupted skin barrier from underlying atopic dermatitis.2 The diagnosis is clinical and is based on history of atopic dermatitis and rapid development of the characteristic rash. This can be confirmed using polymerase chain reaction testing, direct fluorescent antibody staining, or viral culture.3 Eczema herpeticum is often accompanied by a staphylococcal infection,1 although this is not the primary etiology.

Eczema herpeticum is a dermatologic emergency.1 To prevent further dissemination, acyclovir (Zovirax) therapy should be initiated when eczema herpeticum is suspected, and not delayed for laboratory confirmation.3 Additional treatment may include cool compresses; an emollient, such as petroleum jelly; antihistamines to decrease pruritus; and treatment of any bacterial superinfection.3 The condition has a mortality rate of up to 10 percent, even with treatment.2 Topical steroids should be avoided to prevent further insult to the skin's immune response.

The distribution of the contact dermatitis rash is related to the exposure. Erythema is the most common presentation, although vesicles or bullae may occur. Contact dermatitis is pruritic and may lead to visible excoriations. Widespread crusting is uncommon.1

Eczema vaccinatum is a rare cutaneous reaction to smallpox immunization (vaccinia virus). The condition is marked by development of umbilicated vesicles and papules, usually in a uniform stage of development. It occurs in persons with predisposing factors, such as a history of atopic dermatitis, after receiving the smallpox vaccine or after a close contact receives the vaccine.4

Impetigo is common in children and can occur anywhere on the body. The condition sometimes begins as a small vesicle or pustule, but rarely demonstrates widespread vesiculation. The crusting is typically honey-colored, rather than red or brown, and erythema usually is not present.1

Varicella typically begins on the trunk and spreads to the face and extremities. The classic lesion is a pink or red papule that develops into an overlying vesicle. The vesicle then ruptures and crusts. Multiple stages may appear simultaneously.1

Summary Table

Condition Characteristics

Contact dermatitis

Occurs in all age groups; distribution is related to exposure; primarily appears as erythema, but vesicles or bullae may occur; pruritic; widespread crusting is uncommon

Eczema herpeticum

Most common in children two to three years of age; begins on head or neck; dome-shaped vesicles that umbilicate, rupture, and often coalesce; caused by herpes simplex virus 1 infection

Eczema vaccinatum

Occurs on areas affected by atopic dermatitis after exposure to smallpox vaccine; umbilicated papules and vesicles usually in a uniform stage of development

Impetigo

Common in children; can occur anywhere on the body; may begin as a vesicle or pustule, but is rarely widespread; honey-colored crusting

Varicella

Begins on trunk then spreads to face and extremities; vesicle on a pink papule; multiple stages present simultaneously

Summary Table

View Table

Summary Table

Condition Characteristics

Contact dermatitis

Occurs in all age groups; distribution is related to exposure; primarily appears as erythema, but vesicles or bullae may occur; pruritic; widespread crusting is uncommon

Eczema herpeticum

Most common in children two to three years of age; begins on head or neck; dome-shaped vesicles that umbilicate, rupture, and often coalesce; caused by herpes simplex virus 1 infection

Eczema vaccinatum

Occurs on areas affected by atopic dermatitis after exposure to smallpox vaccine; umbilicated papules and vesicles usually in a uniform stage of development

Impetigo

Common in children; can occur anywhere on the body; may begin as a vesicle or pustule, but is rarely widespread; honey-colored crusting

Varicella

Begins on trunk then spreads to face and extremities; vesicle on a pink papule; multiple stages present simultaneously

Address correspondence to H.F. Durtschi, CPT, MC, USA, at hyrum.durtschi@us.army.mil. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

REFERENCES

1. Habif TP. Clinical Dermatology. 5th ed. St. Louis, Mo.: Mosby; 2010:135, 335, 473-474.

2. Buccolo LS. Severe rash after dermatitis. J Fam Pract. 2004;53(8):613–615.

3. Stricker T, Lips U, Sennhauser FH. Visual diagnosis. An 8-month-old infant who has an erupting rash. Pediatr Rev. 2007;28(6):231–234.

4. Moses AE, Cohen-Poradosu R. Images in clinical medicine. Eczema vaccinatum—a timely reminder. N Engl J Med. 2002;346(17):1287.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.


Copyright © 2010 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article