Photo Quiz

Erosions and Vesicles in a Febrile Infant


Am Fam Physician. 2021 Mar 1;103(5):305-306.

A five-month-old child with a history of dry skin presented with a spreading rash that began two days earlier. The patient had one day of fever up to 103°F (39.4°C). The rash began on the patient's cheek and then spread over the trunk and extremities. The patient was feeding well and had no vomiting or diarrhea. The patient was delivered vaginally at full term and was up to date on routine immunizations.

Physical examination revealed that the patient was ill-appearing but nontoxic, with a temperature of 104.3°F (40.3°C). There were diffuse, eroded, and coalescing vesicles on the right cheek, chest, abdomen, back, extremities, and scalp (Figure 1 and Figure 2). The genitals, palms, and soles were spared. There was no lymphadenopathy.






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

  • A. Eczema coxsackium.

  • B. Eczema herpeticum.

  • C. Eczema vaccinatum.

  • D. Impetigo.

  • E. Primary varicella.


The answer is B: eczema herpeticum (also known as Kaposi varicelliform eruption). Eczema herpeticum is a serious complication in patients with chronic skin disease, primarily atopic dermatitis, and is caused by herpes simplex virus 1 infection. Atopic dermatitis, which has a prevalence of up to 17%, results in disruption of the epidermal barrier and impaired cell-mediated immunity.1 This leads to intensely pruritic, inflamed skin and allows for microbial infection.2

Eczema herpeticum is a potentially life-threatening illness that can cause blindness if the eyes are involved and death if severe or untreated.

Address correspondence to Michael Kim, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Boguniewicz M, Leung DYM. Atopic dermatitis: a disease of altered skin barrier and immune dysregulation. Immunol Rev. 2011;242(1):233–246....

2. Freyschmidt E-J, Mathias CB, Diaz N, et al. Skin inflammation arising from cutaneous regulatory T cell deficiency leads to impaired viral immune responses. J Immunol. 2010;185(2):1295–1302.

3. Liaw F-Y, Huang C-F, Hsueh J-T, et al. Eczema herpeticum: a medical emergency. Can Fam Physician. 2012;58(12):1358–1361.

4. Riemenschneider K, Creech CB, Thomsen I. Diffuse papulovesicular rash in an infant with eczema. J Pediatric Infect Dis Soc. 2017;6(4):403–405.

5. Reed JL, Scott DE, Bray M. Eczema vaccinatum. Clin Infect Dis. 2012;54(6):832–840.

6. Hartman-Adams H, Banvard C, Juckett G. Impetigo: diagnosis and treatment. Am Fam Physician. 2014;90(4):229–235. Accessed January 18, 2021.

7. Kennedy PGE, Gershon AA. Clinical features of varicella-zoster virus infection. Viruses. 2018;10(11):609.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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