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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

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

A 5-month-old girl was brought to Primary Health Care Service (PHCS) Kewapante in

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

On this examination, this patient didn’t have a fever as it was verified with a temperature

of 37.0

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

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

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

right arm (Figure 4-6). The worsening condition of the patient made the consideration to figure

there were no laboratory studies ordered in this case since the inability to perform the Tzanck test

and the unavailable of viral and allergy detectors at the PHCS. Consequently, the dermatologist,

via telemedicine, changed the working diagnosis to eczema herpeticum with suspected atopic

dermatitis involvement based on the clinical judgment, which still had a good prognosis,

accompanied by bullous impetigo as the differential diagnosis. This condition was treated with

120 mg of oral acyclovir 4 times/day for five days as the antivirus, a betamethasone ointment twice

a day for dry lesions, an open compress with NaCl 0.9% twice a day for crusted skin, and

continuing pulverized drugs. Additionally, the patient was advised to schedule an appointment for

appointment, she had fully recovered without any sequelae when we met her a year later (Figure

Eczema herpeticum (EH) is an infection caused by herpes simplex virus (HSV) mostly

HSV-1 that causes sores around the face and inside the mouth, which also appear on other body

parts. The EH affects people especially infants under 5 years and young children who have severe

inflammatory skin disease - in this case, it is focused on atopic dermatitis which has barrier

dysfunction. EH presents small, dome-shaped, multiple papule vesicles on an erythematous base

such as Darier’s disease, epidermolysis bullosa simplex, pemphigus foliaceous, Hailey-Hailey

disease, pityriasis rubra pilaris, staphylococcal scalded skin syndrome, ichthyosis, atopic

dermatitis, irritant contact dermatitis, burns, or trauma (Traidl et al., 2021). In our case, the patient

had a first episode of sudden onset of itchy vesicles and papulopustular with crusts starting from

the face down to the neck, back, and extremities at the age of 5 months old without any burn or

Atopic dermatitis (AD) is one of the most common skin inflammatory diseases that is

related to the incidence of EH. AD is characterized by barrier dysfunction such as Filaggrin

mutation which plays a major role in developing AD as it maintains skin hydration, skin pH,

protease activity, desquamation, and lipid synthesis while also keeping the barrier permeability for

and thymic stromal lymphopoietin (TLSP) could activate dendritic cells or directly activate

macrophages to trigger T helper (Th) 2, IL-4, IL-5, IL-13, IL-31, and IL-33 driven inflammation

which could also suppress the filaggrin and decrease the production of interferon- (IFN-), which

has the function to activating dendritic cells, macrophages, Th cells, and natural killer cells that

play role in antiviral defenses, impaired keratinocytes differentiation and provoke itching.

Additionally, there are altered antimicrobial peptides production in AD such as cathelicidin LL-

37, human -defensins (hBD), psoriasin (S100A7), and ribonuclease 7 (RNase 7), which can

directly kill bacteria or virus (Damour et al., 2020; Kim, Kim, & Leung, 2019; Traidl et al., 2021).

The establishment of AD diagnosis is through the fulfillment of Hanifin-Rajka diagnosis

history, and house dust are noted in ADEH+ patients (2). Besides that – the literature says the other

However, eczema herpeticum can be clinically diagnosed when the morphology of the

skin pattern is present, with Tzank smear, direct fluorescent antibody (DFA) testing, and viral

cultures can confirm HSV infection. Neither help nor clinical presentation might be atypical, a

skin biopsy is indicated and the results of laboratory tests are lymphopenia and an increased

The most common organisms that cause complications of EH in bacterial superinfection

HSV infection disseminates systemic infection can occur with fever, malaise, and multiple organ

(Chatproedprai et al., 2015). Moreover, complete blood count (CBC) and the Tzanck test have a

role that can rapidly confirm an HSV infection and also can confirm the diagnosis of EH and rule

out some other diseases. In this case, the patient did not have blood drawn because of not needed

yet in the Primary Health Care Service (PHCS). CBC can distinguish the disease in general

whether bacterial or viral etiology and the study said that the patients who suffer EH have

Another possibility for the underlying skin disease in our case besides AD, is irritant

contact dermatitis (ICD). The patient was given baby oil and powder on the active skin lesion by

her mother despite being advised not to. Irritants could damage epidermal cells, the keratinocytes,

which allow increased permeability to irritants and further inflammation. However, in our case,

three doses per day in children and for the most severe cases - we should consider some conditions

that are related to an individual’s immune system like HIV, prolonged diabetes, undernutrition,

and using corticosteroids or other immunosuppressant medications), these conditions should be

The onset of eczema herpeticum and viral infection during atopic dermatitis may be

significantly impacted by dysbiosis of the skin microbiome. Dysbiosis of the skin microbiome has

been linked to atopic dermatitis and corresponds with the severity of the condition (Bjerre,

Bandier, Skov, Engstrand, & Johansen, 2017). The diverse range of bacteria that make up the skin

microbiota varies depending on the environment, and individual, and ecological characteristics of

each body site (Grice et al., 2009). More than 60% of bacteria linked with the skin belong to three

genders: Corynebacterium (Actinobacteria), Propionibacterium (Actinobacteria), and

Staphylococcus (Firmicutes) (Scharschmidt & Fischbach, 2013). Due to their role in regulating

skin immunity, AMP synthesis, neutrophil recruitment, and defense against pathogens, commensal

demonstrated that a dysbiosis of microbiota caused a more severe HSV-2 infection (Oh et al.,

2016). Patients with atopic dermatitis have an imbalanced lesional skin microbiota due to

significant colonization of S. aureus, which produces toxins such as α-toxin. Together with each

other, these changes promote the invasion, reactivation, and replication of HSV leading to the

Furthermore, because S. aureus produces a large number of virulence factors and may be

linked to an increased risk of viral infections, it is the cause of severe skin infections in people

with atopic dermatitis (Oh et al., 2016). Phenol-soluble modulins (PSMs), another virulence factor

generated by S. aureus, with the capacity to perforate cell membranes (Yamazaki et al., 2017).

Similarly, PSMα can trigger the production of inflammatory cytokines and induce the death of

yellowish crusts on a patient with sanitation issues directs our concern in determining whether the

lesions resulted from primary or secondary bacterial infection instead. Further, follow-up from the

inadequate antibiotic response and skin appearance drives our sight to secondary bacterial

The diagnosis of eczema herpeticum in rural areas could be done by history taking and

clinical appearance. Immediate treatment with acyclovir results in complete recovery and prevents

complications from bacterial infection. A sudden extensive vesiculopustular eruption that doesn’t

respond to antibiotics should be considered as eczema herpeticum with skin barrier impairment