Topical Tacrolimus-Associated Eczema Herpeticum Exacerbated by Prednisone – a Case Report

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Topical Tacrolimus-Associated Eczema Herpeticum Exacerbated by Prednisone – A Case Report Christopher Slater, MD, ACP Associate; Michael T. Morton, MD, FACP • Exempla Saint Joseph Hospital, Denver, CO CASE PRESENTATION A 37-year-old female with a life-long history of eczema, treated with topical tacrolimus daily and intermittent clobetasol for flares, presented with an evolving skin eruption. The rash began as painful red lesions on the left wrist, spreading to her hands, associated with fever and chills. She was seen at her primary care office three days before admission and was prescribed prednisone 40 mg daily, with tapering doses for one week. The following day, the patient’s pain had increased and the skin eruption had spread from her hands to her inner thighs, torso, neck and face. She came to our hospital for further evaluation. HOSPITAL COURSE On admission, the patient had extensive, 1-2 mm, punched-out erosions with eschars, and rare vesicles on an erythematous base, most concentrated on the dorsal and palmer aspects of her hands. The lesions were also present on her inner thighs, neck, face, and upper chest; no mucosal or genital lesions were present. The patient denied a history of herpes infection, but her husband had a remote history of “cold sores”. The patient was diagnosed with eczema herpeticum, which was confirmed by viral culture. She was treated with intravenous acyclovir for HSV-1 and had improvement of her symptoms. DISCUSSION Eczema herpeticum is a disseminated form of herpes simplex virus that complicates atopic dermatitis. Topical tacrolimus, which is used as an alternative to corticosteroids in patients with eczema, has an inhibitory effect on cytokine production, and suppresses cellular immunity by inhibiting T-lymphocyte activation. Its use has been associated with an increased risk of eczema herpeticum. The initiation of prednisone further suppressed this patient’s cellular immunity, worsening the infection. Intravenous acyclovir is the treatment of choice for eczema herpeticum, and should be initiated as soon as the diagnosis is suspected. CONCLUSION Providers need to be aware of the complications of atopic dermatitis, especially eczema herpeticum, and be cautious in prescribing oral steroids to patients who are already using topical tacrolimus. .

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