Clinical Communications Successful treatment of eczema coxsackium with wet wrap therapy and low-dose topical corticosteroid Victoria K. Johnson, DO, Jennifer L. Hayman, MD, Carol A. McCarthy, MD, and Ivan D. Cardona, MD Clinical Implications

 The cutaneous findings of eczema coxsackium may be treated with wet wraps and low-dose topical corticosteroids.  Consider testing for coxsackievirus A6 virus for rapidly progressing vesiculobullous rash, including outside of the seasonal predilection for enteroviral infection.

TO THE EDITOR: Hand, foot, and mouth disease (HFMD) is a common childhood viral illness characterized by vesicles in the mouth, hands, feet, and sometimes the buttocks.1 HFMD has a predilection for the summer and autumn seasons, and historically has been treated with supportive care. Coxsackievirus A16 and enterovirus 71 are the most commonly reported viruses responsible for HFMD.2 Coxsackievirus A6 (CVA6), however, has been associated with more widespread skin lesions and profound tissue destruction.3 Recently, the term eczema coxsackium (EC) was coined to describe patients with underlying atopic dermatitis who present with an eczema herpeticum-like eruption caused by CVA6 with vesicles and erosions in pre-existing areas of eczema. Enteroviral infections, particularly CVA6, should be on the clinicians’ differential diagnosis of children who present with extensive erosions and vesicles, and with a history of eczema.2 We present the first case, to our knowledge, that documents wet wrap therapy (WWT) as a viable treatment option for CVA6 EC, a condition that previously has only been treated with supportive measures. Our patients were 8-month-old former 36-week fraternal twin boys with medical histories significant for eczema. A few days before their January admission, the eczema of both patients were noted to be worsening and not responding to step-up therapy. The primary care physician had escalated therapy from daily moisturizing, as needed over-the-counter class VII topical corticosteroids (TCS), and twice a week diluted bleach baths, to a class V TCS, Hydrocortisone Valerate 0.2% cream (Perrigo Pharmaceuticals, Bronx, New York, New York). The patients were presented to the emergency department with rapid progression of a vesiculobullous rash that involved the face, particularly the perioral area, upper and lower extremities, and trunk. Of note, twin B was diagnosed with otitis media on the day before presentation to the hospital, for which his pediatrician started him on cefdinir. The infants were referred for admission because of worsening skin lesions, fussiness, and dehydration. Laboratory evaluation included a complete blood cell count with differential, comprehensive metabolic panel, and blood cultures. Vesicular fluid was aspirated and sent for herpes PCR, enterovirus PCR, and viral cultures. Intravenous acyclovir and ceftriaxone were started for empiric treatment of herpes and possible bacterial superinfection.

Differential diagnosis included eczema herpeticum, varicella, EC from HFMD, and a severe eczema flare with secondary bacterial infection. Complete blood cell count and comprehensive metabolic panel results were within normal limits. Results of herpes PCR, viral cultures, and blood cultures were negative. The enteroviral PCR results were positive. Further testing by the Centers for Disease Control and Prevention confirmed CVA6. Ceftriaxone and acyclovir were stopped when blood cultures and erpes simplex virus PCR results were negative, and WWT and low-potency Class VI TCS (desonide 0.05% ointment, Taro Pharmaceuticals Inc., Brampton, Ontario, Canada) were started. Although it is well known that WWT, in conjunction with TCS, is an effective and safe treatment for severe flares of atopic dermatitis refractory to increased TCS strength,4 to our knowledge there is no literature that mentions the use of WWT for treatment of EC. The benefits of WWT include an occlusive barrier that prevents scratch-induced skin trauma, increased skin hydration, decreased pruritus and inflammation by cooling of the skin, and increased penetration of the TCS.5 Complications, such as maceration of the skin or secondary skin infections, are possible but have been shown to be uncommon with proper application of WWT.6 Because standard skin therapy was unsuccessful for these patients before admission and because results of enteroviral PCR were positive, which raised our suspicion that this was a possible EC case, we considered the risks and benefits of increasing the potency of the TCS further, commensurate with the severity of the flare, versus implementing WWT with a low-potency TCS. Although there have been no reported complications with patients with CVA6 EC,2 there are no studies that evaluated whether the use of TCS, or occlusion from WWT, increases the risk of complication. Furthermore, there are no studies that evaluated whether the use of TCS, or occlusion from WWT, increases the risk of worsening the cutaneous findings of EC by immunosuppression and leads to more disseminated viral growth. When considering the large body surface area involved, and balancing the uncertainty of the theoretical risks of higher-potency corticosteroids in CVA6 EC with the known benefits of WWT and TCS, we chose to continue treatment with a low-potency TCS with the addition of WWT. Systemic adverse effects from WWT with corticosteroid use were considered; however, prolonged suppression of the hypothalamic-pituitary-adrenal axis has not been reported after short-term treatment with WWT and TCS.7 Therefore, we pursued only short-term use of combined WWT and low-dose TCS for 3 days. Wet wraps were applied 3 times a day, with the morning and evening wraps to include Aquafor (Beiersdorf, Hamburg, Germany) to unaffected areas and desonide 0.05% ointment to the affected areas, and the mid day wrap included Aquafor head to toe. The morning and mid day wraps were worn for an hour, and the evening wraps were worn overnight. Within 24 hours, the patients demonstrated significant clinical improvement, and were discharged after extensive family education to continue the same WWT regimen at home. Twin B also was discharged on cefdinir for the previously diagnosed otitis media. By day 3 after discharge, the patients had improved dramatically, and WWT was discontinued. The twins were seen for follow-up 5 days after discharge and were noted to have had an 803

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CLINICAL COMMUNICATIONS

FIGURE 1. Twins A and B before treatment on the day after admission.

J ALLERGY CLIN IMMUNOL PRACT NOVEMBER/DECEMBER 2014

FIGURE 3. Twins A and B after treatment, 5 days after hospital discharge.

treatment for atopic dermatitis complicated by coxsackievirus. Further studies are needed to evaluate the efficacy and safety of WWT and low-potency TCS treatment of enteroviral infections. Maine Medical Center, Department of Pediatrics, Tufts University School of Medicine, Portland, Maine No funding was received for this work. Conflicts of interest: The authors declare that they have no relevant conflicts of interest. Received for publication April 15, 2014; revised June 17, 2014; accepted for publication July 31, 2014. Available online September 16, 2014. Corresponding author: Ivan D. Cardona, MD, Maine Medical Center, Tufts University School of Medicine, 195 Fore River Pkwy no. 410, Portland, ME 04102. E-mail: [email protected]. 2213-2198 Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2014.07.018

FIGURE 2. Twins in wet wraps during hospitalization.

excellent clinical response (Figures 1-3). The TCS potency was kept at the same level as it was on admission, with the only major change being the addition of WWT, which highlights the synergistic role that WWT and TCS have in cases of complicated eczema. This report highlights an unusual presentation of EC in regard to atypical seasonal predilection and simultaneous appearance in twin cohorts. Accurate rapid viral testing is helpful in the management of this disease process. Finally, to our knowledge, this is the first case report that documents the use of WWT in EC, which highlights that, with careful consideration of adverse effects, WWT with low-potency TCS may be a safe and effective escalating

REFERENCES 1. Centers for Disease Control and Prevention (CDC). Notes from the field: severe hand, foot, and mouth disease associated with coxsackievirus A6-Alabama, Connecticut, California, and Nevada, November 2011-February 2012. MMWR Morb Mortal Wkly Rep 2012;61:213-4. 2. Mathes EF, Oza V, Frieden IJ, Cordoro KM, Yagi S, Howard R, et al. “Eczema coxsackium” and unusual cutaneous findings in an enterovirus outbreak. Pediatrics 2013;132:e149-57. 3. Sung-Hsi W, Ming-Chih L, Tsung-Pei T, Hui-Chen L, Tsuey-Li L, Chen-Yen T, et al. An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010. BMC Infect Dis 2011;11:346. 4. Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics 2008;122:812-24. 5. Schneider L, Tilles S, Lio P, Boguniewicz M, Beck L, LeBovidge J, et al. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol 2013;131: 295-299.e1-27. 6. Devillers AC, Oranje AP. Efficacy and safety of ‘wet-wrap’ dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: a critical review of the literature. Br J Dermatol 2006;154:579-85. 7. Devillers AC, Oranje AP. Wet-wrap treatment in children with atopic dermatitis: a practical guideline. Pediat Dermatol 2012;29:24-7.

Successful treatment of eczema coxsackium with wet wrap therapy and low-dose topical corticosteroid.

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