Pediatric Dermatology Consult - April 2016

By Catalina Matiz, M.D., and David Ginsberg

Eczema cocksackium

Eczema coxsackium (EC) is an atypical variant of hand, foot, and mouth disease (HFMD) that occurs in patients with atopic dermatitis lesions. HFMD is a common viral exanthema seen in pediatric populations, predominantly in children under 5 years of age, and is most commonly caused by coxsackievirus A16 in the United States.1-3 Enterovirus 71 is also a common cause of HFMD in Asian countries, and in rare cases has been linked to more severe neurologic manifestations.2,3 

Over the past several years, infection by coxsackievirus A6 (CVA6) has been responsible for HFMD outbreaks in multiple countries around the globe.1-5 This particular strain of coxsackievirus is known for causing atypical HFMD, which has several overlapping variations. The variants of atypical HFMD caused by CVA6 include eczema coxsackium (EC), widespread vesiculobullous and erosive lesions, purpuric lesions, and Gianotti-Crosti-like eruptions.2 EC is the result of a CVA6 infection in a child with a history of atopic dermatitis (AD). The infection in these patients is a more severe form of HFMD, presenting with eczema herpeticum (EH)-like lesions, with some combination of vesicles, papules, and erosions, in areas affected by atopic dermatitis.2,3 This is in contrast to classic HFMD, which commonly presents with oral erosions, and small vesicles limited to the hands, feet, and buttocks.1,2 

In addition to the dermatologic manifestations, patients with EC also can present with other symptoms including fever and oropharyngeal pain.2,3 Any of the variants of atypical HFMD can present with lesions, including erosions, vesicles, and bullae, in areas of skin irritation such as sunburns, irritant dermatitis, lacerations, and tinea pedis.2 

Differential diagnosis

The differential diagnosis for EC includes EH, impetiginized atopic dermatitis, varicella, and erythema multiforme major.2-4 EH is typically the highest on the differential because the presentation of EC is described as an EH-like rash and on occasion it is difficult to differentiate the two.2 When diagnosing EC, the history plays an important role, and it is imperative to question whether the patient has come into contact with anyone with cold sores to help rule out EH. It is recommended to perform testing for herpes simplex virus (HSV), either by culture, polymerase chain reaction (PCR), or direct immunofluorescence if the diagnosis is not straightforward.2,5 To confirm the diagnosis of EC, CVA6 PCR can be performed.4 The ideal sample would be from vesicular fluid because the same sample also could be used to test for HSV to help rule out EH, but throat swabs and stool samples also can be used.2 As lesions in EH can sometimes be superinfected with bacteria such as Staphylococcus aureus or streptococcus, a bacterial swab for culture and sensitivities is also recommended prior to starting empiric antimicrobial therapy.

Treatment

Because EC was only characterized several years ago, and the majority of the cases reported have been self-limiting, there has been little research done looking into the best treatment. The majority of the literature recommends treating symptomatically in a similar fashion to an eczema flare including daily moisturizing, bleach baths, and topical corticosteroids as needed.6 There has been a report that using wet wraps with lower-strength corticosteroids is an effective treatment method for severe cases.6 Treatment with acyclovir and oral antimicrobials is recommended if the diagnosis of EH is in question and HSV and bacterial testing are pending. 

References

1. JAMA. 2012;308(4):335.
2. Pediatrics. 2013 Jul;132(1):e149-57. 
3. PIDJ. 2014 Apr;33(4):e92-98.
4. Virol J. 2013 Jun 24;10:209.
5. Lancet Infect Dis. 2014 Jan;14(1):83-6.
6. J Allergy Clin Immunol Pract. 2014 Nov-Dec;2(6):803-4.

Dr. Matiz is assistant professor of dermatology at Rady Children’s Hospital San Diego–University of California, San Diego and Mr. Ginsberg is a research associate at the hospital. Dr. Matiz and Mr. Ginsberg said they have no relevant financial disclosures.

By Catalina Matiz, M.D., and David Ginsberg

Eczema cocksackium

Eczema coxsackium (EC) is an atypical variant of hand, foot, and mouth disease (HFMD) that occurs in patients with atopic dermatitis lesions. HFMD is a common viral exanthema seen in pediatric populations, predominantly in children under 5 years of age, and is most commonly caused by coxsackievirus A16 in the United States.1-3 Enterovirus 71 is also a common cause of HFMD in Asian countries, and in rare cases has been linked to more severe neurologic manifestations.2,3 

Over the past several years, infection by coxsackievirus A6 (CVA6) has been responsible for HFMD outbreaks in multiple countries around the globe.1-5 This particular strain of coxsackievirus is known for causing atypical HFMD, which has several overlapping variations. The variants of atypical HFMD caused by CVA6 include eczema coxsackium (EC), widespread vesiculobullous and erosive lesions, purpuric lesions, and Gianotti-Crosti-like eruptions.2 EC is the result of a CVA6 infection in a child with a history of atopic dermatitis (AD). The infection in these patients is a more severe form of HFMD, presenting with eczema herpeticum (EH)-like lesions, with some combination of vesicles, papules, and erosions, in areas affected by atopic dermatitis.2,3 This is in contrast to classic HFMD, which commonly presents with oral erosions, and small vesicles limited to the hands, feet, and buttocks.1,2 

In addition to the dermatologic manifestations, patients with EC also can present with other symptoms including fever and oropharyngeal pain.2,3 Any of the variants of atypical HFMD can present with lesions, including erosions, vesicles, and bullae, in areas of skin irritation such as sunburns, irritant dermatitis, lacerations, and tinea pedis.2 

Differential diagnosis

The differential diagnosis for EC includes EH, impetiginized atopic dermatitis, varicella, and erythema multiforme major.2-4 EH is typically the highest on the differential because the presentation of EC is described as an EH-like rash and on occasion it is difficult to differentiate the two.2 When diagnosing EC, the history plays an important role, and it is imperative to question whether the patient has come into contact with anyone with cold sores to help rule out EH. It is recommended to perform testing for herpes simplex virus (HSV), either by culture, polymerase chain reaction (PCR), or direct immunofluorescence if the diagnosis is not straightforward.2,5 To confirm the diagnosis of EC, CVA6 PCR can be performed.4 The ideal sample would be from vesicular fluid because the same sample also could be used to test for HSV to help rule out EH, but throat swabs and stool samples also can be used.2 As lesions in EH can sometimes be superinfected with bacteria such as Staphylococcus aureus or streptococcus, a bacterial swab for culture and sensitivities is also recommended prior to starting empiric antimicrobial therapy.

Treatment

Because EC was only characterized several years ago, and the majority of the cases reported have been self-limiting, there has been little research done looking into the best treatment. The majority of the literature recommends treating symptomatically in a similar fashion to an eczema flare including daily moisturizing, bleach baths, and topical corticosteroids as needed.6 There has been a report that using wet wraps with lower-strength corticosteroids is an effective treatment method for severe cases.6 Treatment with acyclovir and oral antimicrobials is recommended if the diagnosis of EH is in question and HSV and bacterial testing are pending. 

References

1. JAMA. 2012;308(4):335.
2. Pediatrics. 2013 Jul;132(1):e149-57. 
3. PIDJ. 2014 Apr;33(4):e92-98.
4. Virol J. 2013 Jun 24;10:209.
5. Lancet Infect Dis. 2014 Jan;14(1):83-6.
6. J Allergy Clin Immunol Pract. 2014 Nov-Dec;2(6):803-4.

Dr. Matiz is assistant professor of dermatology at Rady Children’s Hospital San Diego–University of California, San Diego and Mr. Ginsberg is a research associate at the hospital. Dr. Matiz and Mr. Ginsberg said they have no relevant financial disclosures.

By Catalina Matiz, M.D., and David Ginsberg

Eczema cocksackium

Eczema coxsackium (EC) is an atypical variant of hand, foot, and mouth disease (HFMD) that occurs in patients with atopic dermatitis lesions. HFMD is a common viral exanthema seen in pediatric populations, predominantly in children under 5 years of age, and is most commonly caused by coxsackievirus A16 in the United States.1-3 Enterovirus 71 is also a common cause of HFMD in Asian countries, and in rare cases has been linked to more severe neurologic manifestations.2,3 

Over the past several years, infection by coxsackievirus A6 (CVA6) has been responsible for HFMD outbreaks in multiple countries around the globe.1-5 This particular strain of coxsackievirus is known for causing atypical HFMD, which has several overlapping variations. The variants of atypical HFMD caused by CVA6 include eczema coxsackium (EC), widespread vesiculobullous and erosive lesions, purpuric lesions, and Gianotti-Crosti-like eruptions.2 EC is the result of a CVA6 infection in a child with a history of atopic dermatitis (AD). The infection in these patients is a more severe form of HFMD, presenting with eczema herpeticum (EH)-like lesions, with some combination of vesicles, papules, and erosions, in areas affected by atopic dermatitis.2,3 This is in contrast to classic HFMD, which commonly presents with oral erosions, and small vesicles limited to the hands, feet, and buttocks.1,2 

In addition to the dermatologic manifestations, patients with EC also can present with other symptoms including fever and oropharyngeal pain.2,3 Any of the variants of atypical HFMD can present with lesions, including erosions, vesicles, and bullae, in areas of skin irritation such as sunburns, irritant dermatitis, lacerations, and tinea pedis.2 

Differential diagnosis

The differential diagnosis for EC includes EH, impetiginized atopic dermatitis, varicella, and erythema multiforme major.2-4 EH is typically the highest on the differential because the presentation of EC is described as an EH-like rash and on occasion it is difficult to differentiate the two.2 When diagnosing EC, the history plays an important role, and it is imperative to question whether the patient has come into contact with anyone with cold sores to help rule out EH. It is recommended to perform testing for herpes simplex virus (HSV), either by culture, polymerase chain reaction (PCR), or direct immunofluorescence if the diagnosis is not straightforward.2,5 To confirm the diagnosis of EC, CVA6 PCR can be performed.4 The ideal sample would be from vesicular fluid because the same sample also could be used to test for HSV to help rule out EH, but throat swabs and stool samples also can be used.2 As lesions in EH can sometimes be superinfected with bacteria such as Staphylococcus aureus or streptococcus, a bacterial swab for culture and sensitivities is also recommended prior to starting empiric antimicrobial therapy.

Treatment

Because EC was only characterized several years ago, and the majority of the cases reported have been self-limiting, there has been little research done looking into the best treatment. The majority of the literature recommends treating symptomatically in a similar fashion to an eczema flare including daily moisturizing, bleach baths, and topical corticosteroids as needed.6 There has been a report that using wet wraps with lower-strength corticosteroids is an effective treatment method for severe cases.6 Treatment with acyclovir and oral antimicrobials is recommended if the diagnosis of EH is in question and HSV and bacterial testing are pending. 

References

1. JAMA. 2012;308(4):335.
2. Pediatrics. 2013 Jul;132(1):e149-57. 
3. PIDJ. 2014 Apr;33(4):e92-98.
4. Virol J. 2013 Jun 24;10:209.
5. Lancet Infect Dis. 2014 Jan;14(1):83-6.
6. J Allergy Clin Immunol Pract. 2014 Nov-Dec;2(6):803-4.

Dr. Matiz is assistant professor of dermatology at Rady Children’s Hospital San Diego–University of California, San Diego and Mr. Ginsberg is a research associate at the hospital. Dr. Matiz and Mr. Ginsberg said they have no relevant financial disclosures.