Hanke is a 3-years old girl with constitutional eczema and respiratory problems, who you know from your paediatric outpatient department. By prescribing class 2 corticosteroid a temporarily effect has been achieved. During a telephone call her mother tells you that since 2 days the eczema has exacerbated and new spots have developed.In addition, currently Hanke is not feeling well but her mother has not taken the temperature yet. You arrange an emergency consult and you see her that day.
Physical examination of the skin reveals skin lesions as depicted below. Beside the shown lesions there are more lesions in the neck and on her torso and lower extremities, although less severe.
Skin lesions of the patient
J.H. Sillevis Smitt, V.G.M. Geukers & D.E.F.W.M. van Toledo
The diagnosis is based on the “en bouquet” aspect (like herpes labialis) of the punched-like lesions (for example the 3 lesions distal on the left hand). Definitely, it is easier when you are able to examine the total body (there were more round, punched-like lesions also on places where she could not scratch).
Triggered by these findings, you would have focused the history to viral infections. In that case, you would have found out that her mother has had an active herpes labialis three weeks ago, making the diagnosis even more obvious.
The diagnosis Herpes simplex infection is confirmed with a PCR-test. Important is to recognize and treat this viral infection as soon as possible because an ‘eczema herpeticum’ could lead to severe systemic symptoms.
The take-home message of this case is: When a constitutional eczema suddenly does not respond to treatment, you might consider a bacterial or viral infection, or an allergic contact dermatitis to a topical agent.