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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Eczema herpeticum and infected eczema

Dermatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Suspected eczema herpeticum

Rapidly spreading painful monomorphic vesicles or punched-out erosions with fever can disseminate and threaten the eye in people with eczema.

Action: Start systemic aciclovir immediately, obtain same-day specialist advice and arrange urgent ophthalmology for periocular disease without awaiting virology.

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.
  • Bacterial infection is suggested by increasing pain, pustules, purulent exudate, rapidly worsening crust, cellulitis or systemic illness, but eczema often carries bacteria without invasion.
  • NICE advises against routinely offering an antibiotic to a systemically well patient with secondary bacterial infection of eczema because benefit may be limited over topical eczema treatment.
  • Continue emollient and appropriate topical corticosteroid for the underlying eczema during bacterial infection unless a specific clinical reason or specialist plan changes it.
  • For Eczema herpeticum and infected eczema, document body sites, severity, sleep and function, recent treatment, infection features and what the patient can realistically apply each day.
  • In Eczema herpeticum and infected eczema, reassess the diagnosis when a well-used, correctly potent regimen fails rather than repeatedly intensifying treatment without examining adherence, exposure and mimics.

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.

Herpetic systemic signal

Fever, malaise and lymphadenopathy accompanying monomorphic lesions support disseminated HSV and increase admission need.

Periocular threat

Lesions around an eye, red painful eye, photophobia or visual change require urgent ophthalmic assessment.

Investigation priorities

01
Immediate full skin and eye assessmentFirst step

Identify monomorphic HSV, bacterial cellulitis, affected surface and ophthalmic threat.

Management branches

Suspected eczema herpeticumGive antiviral and escalate today

Painful monomorphic vesicles or punched-out erosions occur, particularly with fever, facial or eye involvement.

  1. Start systemic aciclovir immediately, take HSV PCR if this does not delay treatment and arrange same-day dermatology or paediatric advice.
  2. Admit infants, immunocompromised or systemically unwell patients and anyone unable to maintain hydration or oral treatment for intravenous therapy assessment.
  3. Seek urgent ophthalmology for periocular lesions or eye symptoms and assess bacterial co-infection when lesions become purulent or the patient deteriorates.

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.Start early, maintain hydration, reduce dose in significant renal impairment and review neurotoxicity; infants, pregnancy, immunocompromise, eye disease and severe infection need specialist decisions.
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.Check immediate and severe delayed penicillin allergy, liver history, interactions and local resistance; systemic illness, treatment failure or recurrent infection requires reassessment and culture.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG57 atopic eczema in under 12sStepped care, infection recognition and referral for children.
  • NICE NG190 secondary bacterial infection of eczemaAntibiotic thresholds, choice, duration and reassessment.
  • British Association of Dermatologists eczema herpeticumPainful monomorphic eruption, urgency and antiviral care.
  • Aciclovir 200 mg tablets SmPCLicensed herpes-simplex dosing and renal precautions.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom