Vesicular rash in an infant with eczema

The Case

The parents of a healthy 6-month-old boy with eczema bring him to the office for evaluation of a rapidly progressive rash on his arms, legs, face, and back. He had a low-grade fever and loose stools for 2 days last week. 

NEXT: What's the diagnosis?

DERMCASE diagnosis: ECZEMA COXSACKIUM

Etiology

Hand, foot, and mouth disease has been classically associated with the enterovirus coxsackievirus A16 (CVA16) and enterovirus 71 (EV71) in North America. It presents with vesicles and erosions on the hard palate and vesicles with a red to hemorrhagic border on the hands, feet, and occasionally buttocks. A novel presentation with widespread symmetric involvement of the arms, legs, diaper area, and mid-face has been reported with increasing frequency over the last 5 years and has become the new norm (Figure).

Next: Boy with worst-case dermatitis

In children with atopic dermatitis, the enteroviral exanthema is often exacerbated in areas affected by eczema. This presentation, termed "eczema coxsackium," was reported as early as 1968 to be associated with CVA16.¹ Since 2008, eczema coxsackium and the more widespread eruption in children without eczema have been linked to both CVA16 and, more recently, to coxsackievirus A6 (CVA6).^2,3 Coxsackievirus A6 is more often associated with disseminated lesions, including perioral and buttock lesions, than the CVA16 virus.

Eczema coxsackium is most commonly observed among preschoolers in the summer through late fall. However, adult cases and increasing reports of cases in the fall and winter months have been observed with the CVA6 virus strain.^4,5 As with other enteroviruses, CVA6 is spread through fecal-oral transmission.

Clinical manifestations

Eczema coxsackium presents with uniform, clustered, 2-mm to 4-mm vesiculobullous and erosive lesions in regions previously affected by atopic dermatitis, resembling eczema herpeticum. The eruption may consist solely of small vesicles that often evolve into hemorrhagic crusts or confluent hemorrhagic bullae. In addition to areas affected by eczema, CVA6 has a tendency to trigger lesions in regions affected by other trauma such as diaper dermatitis and burns, or in a Gianotti-Crosti-type distribution.

Unlike with eczema herpeticum, CVA6-associated skin findings are not usually linked with fever, decreased appetite, or decreased activity. Rarely, children become dehydrated because of decreased oral intake. Many parents report a brief history of fever or diarrhea during the week before appearance of the exanthema.⁶ Rare, serious complications including aseptic meningitis have been reported.⁷ Onychomadesis, Beau's lines, and desquamation of the palms and soles may develop 1 to 3 weeks after resolution of the rash, which may persist for 2 to 3 weeks.^6-8

Differential diagnosis

The differential diagnosis includes eczema herpeticum, varicella, contact dermatitis, and blistering drug reactions. Diagnosis can be made based on history, presence of systemic symptoms, and reverse-transcription polymerase chain reaction assay from vesicular fluid, throat swabs, or stool samples.

Management

Eczema coxsackium is managed with supportive care. Aggressive use of moisturizer for managing underlying eczema is recommended. Low-potency topical steroids are used for managing itch. Isolation from other children is not necessary.

Outcome

The patient continued to eat and drink normally, and his exanthem crusted over and healed over the next 2 weeks.

REFERENCES

1. Nahmias AJ, Froeschle JE, Feorino PM, McCord G. Generalized eruption in a child with eczema due to coxsackievirus A16. Arch Dermatol. 1968;97(2):147-148.

2. Hubiche T, Schuffenecker I, Boralevi F, et al; Clinical Research Group of the French Society of Pediatric Dermatology Groupe de Recherche Clinique de la Société Française de Dermatologie Pédiatrique. Dermatological spectrum of hand, foot and mouth disease from classical to generalized exanthema. Pediatr Infect Dis J. 2014;33(4):e92-e98.

3. Lott JP, Liu K, Landry ML, et al. Atypical hand-foot-and-mouth disease associated with coxsackievirus A6 infection. J Am Acad Dermatol. 2013;69(5):736-741.

4. Harris PN, Wang AD, Yin M, Lee CK, Archuleta S. Atypical hand, foot, and mouth disease: eczema coxsackium can also occur in adults. Lancet Infect Dis. 2014;14(11):1043.

5. Downing C, Ramirez-Fort MK, Doan HQ, et al. Coxsackievirus A6 associated hand, foot and mouth disease in adults: clinical presentation and review of the literature. J Clin Virol. 2014;60(4):381-386.

6. Mathes EF, Oza V, Frieden IJ, et al. "Eczema coxsackium" and unusual cutaneous findings in an enterovirus outbreak. Pediatrics. 2013;132(1):e149-e157.

7. Lo SH, Huang YC, Huang CG, et al. Clinical and epidemiologic features of Coxsackievirus A6 infection in children in northern Taiwan between 2004 and 2009. J Microbiol Immunol Infect. 2011;44(4):252-257.

8. Bernier V, Labrèze C, Bury F, Taïeb A. Nail matrix arrest in the course of hand, foot and mouth disease. Eur J Pediatr. 2001;160(11):649-651.

Ms Vandiver is a third-year medical student at Johns Hopkins University School of Medicine, Baltimore, Maryland. Dr Cohen, section editor for Dermcase, is professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore. The author and section editor have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. Vignettes are based on real cases that have been modified to allow the author and section editor to focus on key teaching points. Images also may be edited or substituted for teaching purposes.