Eczema Herpeticum: clinical characteristics

Clinical Presentation:

  1. multiple clusters of vesicles in areas of pre-existing skin disease involvement.
  2. Vesicles spread, become hemorrhagic and then crust over.
  3. Painful “punched out” erosions result, these may coalesce to form large bleeding erosions.

The majority of patients will also have fever and malaise.

Patient history:

Patients will often deny previous HSV infection.

In most cases the patient carries HSV asymptomatically

Sub-clinical HSV infection note:

  • 90% of adults have antibodies to HSV-1
  • 20% of adults have antibodies to HSV-2
  • however, far fewer adults manifest the disease.

Differential diagnosis:

  • In any patient presenting with multiple coalescing vesicles and fever HSV infection should be queried.
  • Other causes must be considered.
  • Other viruses are capable of creating a similar clinical picture — most commonly animal pox viruses. A history of zoo keeping or laboratory work should raise suspicion of such viruses.
  • Exacerbation of the primary skin disease should be considered.
  • Blistering disorders, such as pemphigus vulgaris or bullous pemphigoid, may present with a similar appearance, but would not be accompanied by fever.


  1. Punched-out erosions 
  2. vesicles
  3. fever
  4. extreme pain at site(s)


Tzanck preparation

  •  A #15 surgical blade should be used to open the top of a vesicle, scraping the underside of the vesicle as well as the base.
  • The blade is then wiped across a glass slide, heat-fixed, and stained with toluidine blue.
  • A positive prep reveals multinucleated giant cells with molded, jigsaw-puzzle nuclei in addition to acantholytic balloon cells.

WebMD. (2011). Eczema Herpeticum: A dermatologic emergency:  clinical characteristics and diagnosis. Retrieved March 8, 2011 from


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