Eczema herpeticum—a skin condition caused by herpes

If you have eczema, especially the atopic dermatitis type, getting a cold sore can mean a lot more than an inconvenient lesion on your lip. Herpes simplex virus, the virus that causes cold sores or genital herpes, can infect the skin of people with eczema and cause a widespread rash over the face and neck; this is called eczema herpeticum (also known as Kaposi varicelliform eruption). This rash can sometimes spread over broad areas of skin around the body. You can catch herpes simplex virus by sharing utensils, cups, cosmetics, or coming into skin contact with someone who has an open sore. The virus can also live on doorknobs and other inanimate objects. This means that frequent handwashing is important (AAD, n.d.).

Eczema herpeticum looks different from atopic dermatitis or eczema. People with eczema typically have dry, scaly, itchy patches of skin, especially on the cheeks, scalp, forehead, and other parts of the face. However, the rash of eczema herpeticum looks like widespread painful, “punched out” lesions accompanied by swollen lymph nodes in the face and neck, fever, chills, and an overall sense of “not feeling well” (Siegfried, 2015). Eczema herpeticum can also have clusters of small watery blisters that are itchy and painful, blisters that look red, purple, or black, or blisters that ooze pus when broken open (NEA, n.d.).

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Anyone with atopic dermatitis can get eczema herpeticum, but infants and young children are the ones most often affected, especially if they have moderate to severe eczema (AAD, n.d.). Approximately 10–20% of people with atopic dermatitis develop eczema herpeticum (Siegfried, 2015). We don’t know why some people exposed to the herpes simplex virus simply get cold sores while others get full-blown eczema herpeticum. We do know that atopic dermatitis affects the health of the skin and skin barrier—this can make the skin more susceptible to infections. People with other skin conditions, like contact dermatitis or seborrheic dermatitis (a non-eczema type of dermatitis), can also get eczema herpeticum from a herpes simplex virus infection (NEA, n.d.).

It takes up to two weeks for the eczema herpeticum rash to appear after you come into contact with the herpes simplex virus. The infection usually starts in skin affected by eczema and then spreads to involve normal skin over 7–10 days (Santmyire-Rosenberger, 2005)

Skin findings:

• Widespread rash on face and neck

• Rash that spreads to other areas of the body

• “Punched out” lesions 

• Clusters of small watery blisters that are itchy and painful

• Blisters that look red, purple or black or that ooze pus when they break open

Other symptoms:

• Fever and chills

• General malaise (not feeling well)

• Swollen lymph nodes in the areas of the rash

In severe cases of infection, you can get complications from eczema herpeticum. Some people can get scarring from all of their blisters. If the virus gets near the eye, you can get an infection of the cornea of the eye—herpetic keratitis. Herpetic keratitis can lead to scarring and blindness if it is not recognized and treated. In people with a weak immune system, eczema herpeticum can be life-threatening; the infection can spread via the bloodstream and lead to organ failure and death (NEA, n.d.).

Your healthcare provider can sometimes diagnose eczema herpeticum just by looking at it, but often a skin sample helps confirm the diagnosis. He or she may begin by scraping the infected skin and looking at the contents of the blisters under the microscope (this is called a skin smear) (AAD, n.d.). Also, viral cultures and polymerase chain reaction (PCR) testing can help identify what is causing the infection (Siegfried, 2015). 

Why is all of this necessary if the provider can tell by appearance? Sometimes eczema herpeticum resembles another skin infection called impetigo. Impetigo is a bacterial skin infection, usually with Staphylococcus aureus or Streptococcus pyogenes, which are common skin bacteria. People with atopic dermatitis are more susceptible to impetigo than those without eczema. Impetigo usually has redness, swelling, tenderness, and honey-yellow crusting of infected skin (Siegfried, 2015). The treatment of the two conditions is different, one being a viral infection and the other caused by bacteria. The additional testing mentioned can help differentiate between the two when necessary.

Since it is caused by a virus, the best treatment for eczema herpeticum is an antiviral medication, like acyclovir (intravenous or by mouth) or valacyclovir (by mouth) (Santmyire-Rosenberger, 2005). These drugs help fight off the current outbreak but do not prevent future flare-ups. Some people get bacterial skin infections on top of the viral infection (secondary bacterial infection) and need antibiotics as well. If the eczema herpeticum is severe, you may require hospitalization until your condition improves. 

If you have any form of eczema and you develop a different kind of rash, especially one that is painful or forms blisters, see your healthcare provider for an evaluation. You may have a skin infection. Most of the time, in healthy people, prompt recognition and treatment can lead to a mild disease with few long-term consequences. 

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Current version

February 26, 2020

Written by

Chimene Richa, MD

Fact checked by

Mike Bohl, MD, MPH, ALM

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About the medical reviewer

Mike Bohl, MD, MPH, ALM

Dr. Mike is a licensed physician and a former Director, Medical Content & Education at Ro.