How to cite:
Nur Aida Oktasari, Adisty Ridha Damasuri, Indah Sari, Anita Tanuwijaya (2024), Challenge in
Diagnosis of Eczema Herpeticum in Rural Area in East Nusa Tenggara: a Case Report, (6) 05, _ _
Published by:
Ridwan Instute
Nur Aida Oktasari, Adisty Ridha Damasuri, Indah Sari, Anita Tanuwijaya
RSUD dr. R. Soeprapto Cepu, Kabupaten Blora, Jawa Tengah, Indonesia.
Eczema herpeticum is an infection caused mostly by the herpes simplex virus which arises from
an impaired skin barrier that may have a life-threatening bacterial complication. This case report
unfolds the clinical reasoning behind diagnosing and treating eczema herpeticum in a rural area in
East Nusa Tenggara, Indonesia, that has limited healthcare facilities in favor of recovery without
any sequelae. We describe a 5-month-old girl who has dry skin with acute extensive itchy vesicles
and papulopustular with crusts starting from the face down to the neck, back, and extremities that
worsened even after receiving antibiotics yet showed improvement after receiving acyclovir.
Keywords: Eczema herpeticum, rural area, East Nusa Tenggara, case report
Eczema herpeticum, also known as Kaposi varicelliform eruption or pustulosis acuta
varioliformis, is a sudden extensive vesiculopustular eruption usually caused by Herpes Simplex
Virus (HSV) which arises from pre-existing skin disease, such as atopic dermatitis (Liaw, Huang,
Hsueh, & Chiang, 2012; Traidl, Roesner, Zeitvogel, & Werfel, 2021). It has been stated that around
3% of atopic dermatitis patients are predicted to develop eczema herpeticum during their lifetime
and 90% of them are caused by HSV-1 (Beck et al., 2009; Damour, Garcia, Seneschal, Lévêque,
& Bodet, 2020; Leung, 2013; Sanga, Darius, Rangga, & Naga, 2018). The diagnosis and treatment
of eczema herpeticum should be concluded rapidly as untreated eczema herpeticum may lead to a
life-threatening infection (Liaw et al., 2012; Satria, Chen, Soebono, Radiono, & Danarti, 2019;
Sharif & McMullen, 2018).
Sikka Regency is one of the rural areas in East Nusa Tenggara Province, Indonesia, which
still has many health welfare obstacles such as limited healthcare facilities and the existence of
slums area which may contribute to the higher morbidity rate in rural areas compared to the urban
area from the year 2020 to 2022 (Statistik, 2019) This report presents a challenging case of
diagnosing eczema herpeticum in a rural area in East Nusa Tenggara.
Case Report
pISSN: 2723-4339 e-ISSN: 2548-1398
Vol. 6, No. 05, Mei 2024
Challenge in Diagnosis of Eczema Herpeticum in Rural Area in East Nusa Tenggara: a Case
Syntax Idea, Vol. 6, No. 05, Mei 2024 2383
A 5-month-old girl was brought to Primary Health Care Service (PHCS) Kewapante in
Sikka Regency, East Nusa Tenggara, with vesicles on the face, neck, and left extremities for 3
days. The vesicles started as a single clear blister on the face and spread down to the neck and left
extremities, but there wasn’t any vesicle found on the body. This was the first time for the baby to
experience vesicles as she was a healthy full-term newborn, despite the 2000-gram birth weight.
The vesicles were itchy as the baby scratched them until the vesicles turned into pustules that were
broken into round erythematous collarette crusts. This patient also had intermittent nocturnal dry
cough along with the vesicle eruption. There was no complaint of runny nose, fever,
gastrointestinal tract, or micturition problems nevertheless. At that time, this patient only breastfed
and never had other kinds of foods or drinks, including fortification milk. On the other hand, this
patient, who lived in a water shortage area, bathed twice a day with baby soap and water from a
rainwater tank which rarely cleaned. Moreover, she always had dry skin, which was similar to her
friends who had the same complaint but never sought any medical advice. However, a history of
atopy in the patient or her family was denied. Thus far, her mother gave initial treatment such as
baby oil and powder to the lesions, yet no improvement was seen.
On this examination, this patient didn’t have a fever as it was verified with a temperature
of 37.0
C. However, there were multiple discrete round herpetiform vesicles some of which were
in the pustules and collarette crusts form on the face, a collarette crust on the left palm, and a
vesicle on the left sole (Figure 1-3). Additionally, there were no other physical abnormalities found
on the examination. Hence, there were no laboratory studies ordered at that moment. This patient
was examined by a general practitioner who consulted a dermatologist who was available only at
a hospital in Maumere, the capital of East Nusa Tenggara, via telemedicine. The dermatologist
diagnosed the patient with bullous impetigo which had a good prognosis, accompanied by varicella
and atopic dermatitis as the differential diagnosis. Therefore, the dermatologist prescribed an
amoxicillin drop of 0.7 ml 3 times/day for a week, a chloramphenicol ointment 3 times/day for a
week, and pulverized drugs consisting of 0.6 mg of CTM, 3 mg of ambroxol, 5 mg of vitamin C,
and 1/10 tablet of vitamin B complex, which taken 3 times/day for a week. The patient was also
advised to maintain hygiene, avoid excessive sweating, keep the nails short, not use any
unprescribed oil or powder, avoid scratching, and schedule an appointment for the following week.
On the second appointment at PHCS Kewapante, which was delayed a week after the initial
schedule, the patient's complaint was the reappearing of vesicles together with pustules and
collarette crusts after taking the drugs even though previously showed a temporary mild
improvement. The vesicles spread to the back and right arm in addition to more severe vesicles on
the face, which were accompanied by erythematous patches. The application of baby oil and
powder to the lesions was continued even though it was not recommended. The nocturnal dry
cough remained, and further elaboration showed that the patient was living with heavy smokers.
There were no other complaints.
On this checkup, there were more vesicles and papulopustular with many yellowish crusts
on erythematous bases on the face that extended to the scalp, multiple papulovesicular alongside
erythematous patches on the back, and multiple discrete vesicles with halo erythematous on the