Herpetic eczema

Description:

Herpetic eczema (old names: varioliformny пустулез Kaposhi-Yuliusberg, acute ospennovidny пустулез Yuliusberg) - is the disseminated gerpesovirusny infection complicating a current of a chronic dermatosis with skin erosive cankers at children of younger age, is more rare at teenagers and adults, and developing against the background of immunity disturbances.

The Hungarian scientific Kaposi M. in 1887 described characteristic changes on skin and connected them with the general disturbance of a condition of the patient. In 1883 Kaposi called it za6olevaniye herpetiform eczema - "eczema herpetiforme". In 1898 Jliusberg S. described this dermatosis as "pustulosis acuta varioliformis" and assumed its virus etiology. It included in the concept "acute varioliformny пустулез" as the rashes observed at herpetic eczema and the rashes arising in response to introduction of a vaccinal virus strain of natural smallpox or at contact of the patient with a chronic dermatosis with the children who received a bovine vaccine. This association of two diseases, similar in a clinical picture, a long time complicated epidemiological investigation. Now similar mistakes are excluded as in connection with elimination of incidence of smallpox and the termination of vaccinations emergence of vaktsiniya is impossible.

In spite of the fact that in 1912 the herpes simplex virus (HSV) was allocated to Gruter W., and in 1941 Esser M. and Seidenberg S. and Ruchman A. and Welsh A. in 1947 proved that the activator at gepetichesky eczema is VPG, in domestic dermatology up to 50-60 years concepts of vaktsiniya and herpetic eczema were not divided. In our country the etiological role of VPG in development of herpetic eczema was confirmed E. L. Kiefer (1958) and A. A. Vitko (1970).

The big contribution to a research of herpetic eczema was made by F.A.Zverkova, S. Ya. Golosovker who in 1955 for the first time in Russia described 10 patients with this dermatosis. During the whole next years studying of features of epidemiology, clinic, disease and improvement of therapy continued.

Now numerous old names of this dermatosis which dermatologists used earlier are replaced with the term herpetic eczema which, in our opinion, most accurately reflects the nature of this dermatosis and is convenient for diagnosis.

Symptoms of Herpetic eczema:

The incubation interval usually makes 2-7 days, can sometimes be extended up to 10 days. Seasonal rise in incidence of herpetic eczema is noted in the second half of fall, in the winter, and also at the beginning of spring.

Herpetic eczema complicates a current of a chronic dermatosis at which there are skin erosive cankers. Develops in 90-95% of cases of herpetic eczema at patients with atopic dermatitis. 5-10% are the share of other chronic dermatosis. In literature cases of developing of herpetic eczema against the background of seborrheal dermatitis, chronic eczema, a high-quality family pemphigus of Guzhero - Hailey - Hailey, diseases to Darya are described, at thermal burns, an acne, fungoid mycosis, a vulgar pemphigus.

The acute beginning is in most cases characteristic. In certain cases the acute period is preceded by a prodromal stage during which drowsiness, slackness, indifference of the child is noted.

Duration of a prodromal stage can make 1-3 days and comes to an end with sharp deterioration in the general condition of the child and rise in body temperature to 39-40 C. Breath and pulse become frequent. So, at the heavy course of herpetic eczema the expressed toxicosis which is shown the expressed short wind, tachycardia, a priglushennost of cardiac sounds is noted, spasms, anorexia and other neurologic symptoms can join. At a number of patients the disease can proceed in easier form, characterized by rise in body temperature to 38C, rather satisfactory general condition of patients without the noticeable phenomena of toxicosis. The feverish period on average lasts 6-10 days and matches the period of rashes. It is noted that temperature reaction at patients with herpetic eczema has constant character with fluctuations within a day within one degree and badly gives in to influence of antipyretics.

The most frequent localization of the centers of defeat: face skin (cheeks, a forehead, zaushny folds, auricles), a pilar part of the head, a neck, upper extremities (a dorsum of brushes, forearms), is more rare a dorsum of feet, a trunk, buttocks. At certain patients with earlier hard proceeding chronic dermatosis elements of rash can cover all integument. In such cases rash has generalized distribution.

The most important for diagnosis of herpetic eczema is existence of a typical enanthesis (on mucous membranes of a rash are ephemeral and quickly turn into erosion), which allow to establish the correct diagnosis timely. Against the background of sharp temperature increase the expressed hypostasis and an inflammatory erythema of a child's face are noted. Further within 6-12 hours appear, consistently being exposed to evolution, papulovesicules, vesicles with serous, serous and hemorrhagic contents, pustules. Vesicles and pustules at herpetic eczema have a typical appearance: rashes about one size (1-3 mm in the diameter), a dome-shaped form, with pupkoobrazny retraction in the center and the inflammatory roller on the periphery. Rashes are plentiful, the herpetiform arrangement is characteristic: the majority of elements are grouped. Also perhaps and the chaotic arrangement which is quite often reminding rashes at chicken pox. On a face of a pustule owing to their abundance almost merge and form the characteristic centers. At the edges of the centers the separate isolated typical pustules are disseminated.

In the course of evolution band elements are opened, erosion merge among themselves, forming the huge sites deprived of epidermis, further elements dry up, becoming covered brownish корчневыми by hemorrhagic crusts. Characteristics of rashes at herpetic eczema are: the increased vulnerability of skin, formation of the bleeding erosion, deep cracks and stratification of massive hemorrhagic crusts.

Within a week of a disease there can be new elements and around the main center, and on not affected skin.

At not complicated course of a disease in 6-10 days hemorrhagic crusts disappear. Sometimes on site rashes there is a superficial atrophy in the form of the scarcely noticeable, roundish, slightly pressed hems of 3-5 mm in size in the diameter, large hems of a polycyclic configuration are more rare.

At emergence of vezikulo-pustular rashes, typical for herpetic eczema, the clinical picture of the previous atopic dermatitis usually weakens or disappears. When herpetic rashes are resolved also high temperature of a body of the patient critically or lytically decreases, in the centers again into the forefront clinical displays of atopic dermatitis, or other skin process preceding herpetic eczema act.

Along with an enanthesis quite often mucous membranes of an oral cavity, a throat are involved in pathological process, - can develop keratokonjyuktivit, and also defeat mucous generative organs.

At herpetic stomatitis of a rash are localized most often on a mucous membrane of cheeks, gums, the sky, the internal surface of lips, in language, is more rare on a soft and hard palate, palatal handles and almonds. Process has limited character and represents vesicular and erosive islands from the remains of the exfoliated epidermis located on erythematic and edematous sites of a mucous membrane of a mouth. Gingivas throughout at herpetic stomatitis are edematous. In the sky the merging erosive centers with scalloped contours can be formed. At a glossitis in language among a dense white plaque rare vesicles of rounded shape are visible. The irritation of a mucous membrane leads to constant hypersalivation. Because of morbidity meal is limited.

Damage of eyes at herpetic eczema meets in 10-15% of cases and most often proceeds either in the form of a konjyuktivit, or in the form of a keratokonjyuktivit. At a herpetic konjyuktivit mucous a century, an eyeglobe, edges a century it is hyperemic. The moderate photophobia and dacryagogue are characteristic.

Herpetic defeat of generative organs is characterized by ostrovospalitelny manifestations. At boys of a rash are localized on an internal leaf of a prepuce, on a head, a neck and a body of a penis. At girls small vulvar lips, a clitoris, a vagina are surprised more often. Rashes are also presented by vesicles, erosion, ulcers against the background of an erythema and puffiness, often are followed by morbidity, an itch. When involving in process of a mucous membrane of an urethra morbidity at an urination appears and serous allocations from an urethra.

At extremely heavy course of herpetic eczema which meets in 10-15% of cases (Zverkova F. A. – 1985, Adaskevich V. P. – 2001), often proceeding with the expressed toksiko-septic syndrome, the lethality among patients reaches 10-50%. Terrible complications are causes of death of patients: acute hypostasis and stenosis of a throat, disturbance of a heart rhythm, heavy pneumonia, damages of kidneys, liver. According to F.A.Zverkova (1985) at 10% of sick children spasms, the fontanel tension, a stiff neck and other meningeal symptoms owing to development of meningitis and an encephalomeningitis were observed.

At herpetic eczema development of septic complications in a look strepto-and staphylodermas, purulent otitis, sepsis is possible. At children up to one year herpetic eczema proceeds most hard and development of complications in this group of patients is most probable.

At all patients regardless of disease severity regional lymphadenitis is noted: increase in submaxillary, cervical, occipital lymph nodes. In 60% of cases the gepatosplenomegaliya, in 20% - a splenomegaly is noted. At a number of patients the frustration of a chair which is expressed in its increase, fluidifying is registered.

For the first time the arisen herpetic eczema proceeds on average 10-20 days. A recurrence proceeds easier, without disturbance of the general state.

Reasons of Herpetic eczema:

Today herpetic eczema can be considered as one of forms of a herpes simplex (Herpes simplex), or simple bubble depriving. The activator of a herpes infection is VPG DNA-containing. Most of researchers subdivide VPG into two types: VPG-1 and VPG-2 (Herpesvirus hominis typus 1, typus 2). In the majority GEK is caused by VPG-1.

It is noted that herpetic eczema develops more often at children at whom atopic dermatitis arose in earlier terms – on the 2nd month of life. The most part of the children having herpetic eczema from early age was on artificial feeding.

Incidence of herpetic eczema is higher at children aged from 6 months up to 2 years, herpetic eczema occurs at teenagers and adults seldom. Emergence of this complication at early children's age is caused by sharp falling vnutriutrobno of the transferred antibodies to VPG by 6 months of life and emergence of own antibodies to a herpes virus only by 2-3 years. According to A. A. Vitko studying antibodies to VPG at children of early age, dynamics of change of quantity of antibodies following: at children aged from 4 days up to 5 months in 94% of cases antibodies to VPG were defined, children have from 6 to 12 months – in 20%, and aged from 1 year up to 2 years the quantity increases to 60% since the child has already own antibodies. It explains the peak of incidence of herpetic eczema falling on 7-12 months of life of the child.

The risk group is made by children with a SARS and receiving locally therapy by glucocorticosteroid means, and also children and adults on immunosuppressive therapy concerning a gematoonkologiya and other somatic pathology.

Treatment of Herpetic eczema:

Treatment of patients with herpetic eczema has to be complex: taking into account the general condition of the patient, prevalence, character and stages of rashes, their localization, associated diseases and complications. Hospitalization of patients is obligatory. Constant observation of the doctor in the conditions of infectious department is required. Patients with herpetic eczema need to be isolated from other patients in the boxed chambers since they can be a source of infection of other children having atopic dermatitis or other dermatosis.

The diet at patients of GEK has to correspond to age. For children of chest age recommend to continue breastfeeding. For the purpose of a detoxication frequent drink is recommended, at serious condition transfusion therapy is shown: intravenous injection of 5-10% of solution of glucose, normal saline solution from 5% solution of ascorbic acid and 50-100 mg of cocarboxylase. In cases of the expressed intoxication administration of freshly frozen plasma, 10% of solution of albumine of 10 mg/kg of weight of the child is necessary. At emergence of neurologic symptoms patients have to be consulted by the neuropathologist.

Causal antiherpetic treatment by the patient is appointed from the first day of receipt in a hospital. In children's practice choice drug for treatment of a herpes infection is the acyclovir. The acyclovir became the first highly effective antiherpetic drug which blocks synthesis of DNA of a virus and protects not infected cells. The hypotoxicity of an acyclovir is explained by the fact that it passes into an active phase in the presence of a virusospetsifichesky thymidinekinase, influencing, thus, only the infected cells, blocking synthesis of virus DNA and protecting not infected cells. The acyclovir has no immunosuppressive properties. The acyclovir elimination half-life from an organism about 3 hours, and drug is brought to 90% with urine and in not changed look. To the children of younger age suffering from GEK enter an acyclovir intravenously in a dose of 5 mg/kg of weight each 8 hours within 5-8 days, at the weakened immunity of a dose increase up to 10 mg/kg of weight a day. Purpose of an acyclovir inside for adults and to children is more senior than 12 years is made at the rate of 5 mg/kg of body weight each 8 hours.

From the first day the patient with herpetic eczema for the purpose of increase in immunity enters intramusculary antiherpetic immunoglobulin 1 dose in 2-3 days on a course of 3-5 injections once a day

At the same time for reduction of an itch and concern at patients (especially during subsiding of displays of herpes) purpose of antihistaminic drugs (Dimedrol, Suprastinum, tavegil, Diazolinum), and also a calcium gluconate in age dosages is shown.

At the expressed intoxication syndrome, proceeding with disturbance of cordial activity, to children appoint cardiac glycosides. It is reasonable to all patient to appoint vitamin A in drops inside, and also Bl vitamins, B2, Wb, B12, C or Ascorutinum.

For the prevention of dangerous bacterial complications antibacterial drugs (aminopenicillin, cephalosporins of the second and third generation) by a course of 7-10 days in age dosages are used.

In complex therapy of herpetic eczema purpose of immunotropny drugs is also shown. Now in complex therapy of a herpes infection well proved drugs of interferon which, being esteystvenny factors of nonspecific protection and mediators of immunity, possess the widest Spector of antiviral action. The most effective and convenient drug in children's practice is виферон, recombinant interferon alfa2b, having anti-virus, anti-proliferative and immunomodulatory activity. Drug is appointed on 2 candles a day daily within 5 days. Then a discontinuous course on 1 candle 2 times a day 3 times a week within 4 weeks, further 2 times a week within 2 months. To children of chest age appoint Viferon-1 containing 150000 ME to children up to 7 years Viferon-2 containing 500 000 ME is recommended, and to children 7 years – Viferon-3 containing 1 000 000 ME are more senior.

Outside treatment of herpetic eczema is defined by a process stage. In an initial stage of process not opened bubbles and pustules tushirutsya by 1% spirit solution diamond green 2-3 once a day. At an acute face edema, a bright erythema, the bleeding erosion the centers are processed by 1% aqueous solutions of diamond green and methylene blue. After a tushirovaniye of the centers aniline dyes of a rash grease with antiherpetic ointments. It is necessary to appoint antiviral means for external use no later than 48 hours after emergence of herpetic rash. In treatment of herpetic eczema at children outwardly apply 5% atsiklovirovy ointment or cream, 3% vidorabinovy cream, epigen-spray, viferonovy ointment, etc. On massive hemorrhagic crusts impose 0,5-1% of ointment with Aethacridinum of a lactate, 2-3% boron-нафталановую, or 3% dermatolovy ointments. Violent removal of hemorrhagic crusts at patients with herpetic eczema is inadmissible that can lead to severe bleeding, formation of deep erosion, cracks, and in the subsequent and rough hems on a face at the child. For acceleration and simplification of rejection very dense and massive геморрагическнх crusts on them for 2-4 hours impose the napkin from 4-6 layers of a gauze which is plentifully impregnated 5% with streptotsidovy linimentum, zinc oil, metiluratsilovy ointment or cream with Actovegin and solkoserily. After an otkhozhdeniye of crusts keratoplastichesky pastes are applied (2-3% naftalanovy, Lassar's paste). At herpetic eczema contraindicated topical administration of ointments corticosteroids.

Topical treatment at damage of a mucous membrane of an oral cavity consists in performing also antiviral therapy. At herpetic stomatitis of v of patients with herpetic eczema apply 5% atsiklovirovy ointment, 2% alpizorinovy ointment, 1% tebrofenovy ointment, epigen-spray. These drugs are appointed 3-4 times a day. Antiviral drugs need to be applied on all mucous membrane, and not just on affected areas as they give both medical, and preventive effect. Once a day an oral cavity is recommended to process 0,1-0,5% solution of proteolytic enzymes (trypsin, chymotrypsin, Pancreatinum, etc.) which promote dissolution of nekrotizirovanny fabrics. During fading of a disease good results are yielded by applications of Solutio oleosa of vitamin A, oil of a dogrose, karotolin, ointment and jelly of a solkoseril, ointment with methyluracil.

Irrespective of localization of rash on the child's skin with herpetic eczema it is necessary to consult at the oculist. At herpetic damage of eyes from the first days appoint antiviral means: 3% an oculentum of an acyclovir of 4-5 times a day, interferon in eye drops of 6-8 times a day, OFTAN-IDA, Kerecidum, Poludanum. Duration of external use of any of drugs should not exceed 7-10 days. As the means strengthening medical effect of antiviral drugs apply antioxidants: 5-10% tocopherol Solutio oleosa in the form of instillations or eye 1% of a drop of an emoksipin 3 times a day. For reparative treatment of a cornea eye gel of a solkoseril, 3% eye drops of Etadenum are used.

The forecast of herpetic eczema always very serious owing to a possibility of life-threatening complications. According to literature the lethality at herpetic eczema makes from 5-30%. Sepsis, pneumonia, an encephalomeningitis are the most frequent causes of death. Considerable decrease in quantity of complications is observed at timely diagnosis, careful care of children, early and rational treatment in the first hours after receipt in department and establishments of the diagnosis.