Synopsis
Differentiate eczema herpeticum from bacterial impetiginisation and a non-infected flare, start time-critical antiviral treatment, and use antibiotics only when clinical severity warrants them.
- Eczema herpeticum causes a sudden painful eruption of monomorphic vesicles and punched-out erosions, often with fever or malaise; ordinary eczema is usually itch-dominant and polymorphic.
- Start systemic aciclovir immediately when eczema herpeticum is suspected and arrange same-day specialist assessment; do not wait for HSV PCR.
- Periocular lesions, painful red eye, photophobia or visual symptoms require urgent ophthalmology as well as antiviral treatment.
Key red flags
Eye pain, photophobia, periocular vesicles, fever, malaise, rapidly spreading painful erosions, systemic illness, immunosuppression, infant age or dehydration requires urgent hospital assessment.
Fever, malaise and lymphadenopathy accompanying monomorphic lesions support disseminated HSV and increase admission need.
Investigation priorities
Identify monomorphic HSV, bacterial cellulitis, affected surface and ophthalmic threat.
Management branches
Painful monomorphic vesicles or punched-out erosions occur, particularly with fever, facial or eye involvement.
- Start systemic aciclovir immediately, take HSV PCR if this does not delay treatment and arrange same-day dermatology or paediatric advice.
- Admit infants, immunocompromised or systemically unwell patients and anyone unable to maintain hydration or oral treatment for intravenous therapy assessment.
Key medicines
Aciclovir 200 mg tabletsFor adult herpes-simplex skin infection take 200 mg orally five times daily at roughly four-hour intervals, omitting the night dose, for five days; extend severe initial infection under specialist care.
Flucloxacillin oral therapyFor adults with secondary bacterial infection of eczema when oral antibiotic is indicated, use 500 mg orally four times daily for five to seven days according to NICE NG190.