Eczema herpeticum in a child — SCE Dermatology MCQ

Correct answer: A — Same-day systemic aciclovir and ophthalmology assessment

The correct answer is A, same-day systemic aciclovir and ophthalmology assessment. Fever, irritability, and sudden clusters of monomorphic punched-out erosions on the face and neck in a child with atopic eczema are classic for eczema herpeticum, a disseminated HSV infection superimposed on eczematous skin. Pain rather than itch is a key discriminator from a simple eczema flare or bacterial infection, and periocular involvement raises the risk of herpetic keratoconjunctivitis and corneal scarring, mandating urgent same-day ophthalmological review alongside dermatological input. NICE quality standards state that eczema herpeticum requires immediate systemic (oral or intravenous) aciclovir, with same-day ophthalmology referral if lesions are periocular, because delay risks rapid dissemination and ocular complications. Why the other options are wrong: B. Increase topical corticosteroid alone: Topical steroids are immunosuppressive locally and would worsen viral replication and dissemination in untreated HSV infection, risking eczema herpeticum progressing to widespread or life-threatening disease. C. Start oral flucloxacillin and review in one week: Flucloxacillin targets staphylococcal superinfection, not HSV, and a one week review is unsafe given the risk of rapid ocular and systemic spread within days. D. Apply permethrin cream overnight: Permethrin treats scabies, which presents with intense itch and burrows, not painful punched-out erosions with fever. E. Use topical antifungal cream to facial lesions: Antifungals treat dermatophyte or candidal infection, which do not cause monomorphic punched-out erosions or systemic upset in this pattern. Key point: Painful monomorphic punched-out erosions with fever in an eczematous child, especially near the eyes, is eczema herpeticum until proven otherwise and needs same-day systemic aciclovir plus ophthalmology review.

Reference: NICE Quality Standard QS44, Atopic eczema in under 12s, Quality statement 7: Treatment of eczema herpeticum, https://www.nice.org.uk/guidance/qs44/chapter/quality-statement-7-treatment-of-eczema-herpeticum