For Children With Atopic Dermatitis, a Cold Sore Can Be Dangerous

Usually, a cold sore is benign and temporary — nothing more than an inconvenience. But for children with atopic dermatitis, catching the herpes simplex virus (HSV-1) that causes it can be quite harmful.

“Healthy skin acts as a protective barrier that helps keep viruses, bacteria, and other irritants out,” says Jody A. Levine, MD, a pediatric dermatologist in New York City. “In children with atopic dermatitis, that barrier is disrupted, leaving tiny cracks in the skin that make it easier for germs to enter.”

Though a cold sore can also be harmful to adults with moderate-to-severe eczema, children with the same type of atopic dermatitis are even more at risk when exposed to HSV-1.

That’s partly because children have developing immune systems and thinner skin barriers than adults, so they’re already at a higher risk of catching viruses and getting infections.

“If a child with eczema is exposed to HSV-1, the virus can spread rapidly through areas where the skin barrier is damaged,” says Dr. Levine. “Instead of remaining confined to a small cold sore on the lip, it can infect large areas of skin.”

In short, “Children with moderate-to-severe eczema are at the greatest risk, because they have more extensive barrier disruption,” says Levine.

The most important thing when dealing with cold sores and atopic dermatitis in kids is to know what to look for and be aware of the difference between a normal atopic dermatitis rash and signs of eczema herpeticum.

“Unlike a routine eczema flare, which is usually characterized by itchy, dry, inflamed patches, eczema herpeticum is often painful, rather than just itchy, and may be accompanied by fever, swollen lymph nodes, and fatigue,” says Levine. “This is a viral infection, not just inflammation, so it requires prompt treatment with antiviral medication.”

The first signs of eczema herpeticum typically pop up 5 to 12 days after exposure to HSV-1 or a cold sore and tend to appear as:

• One or more clusters of small, painful red, purple, or black blisters that tend to have a more dramatic appearance than regular atopic dermatitis
• Intense itchiness and pain
• Blisters that look like hole-puncher marks and are usually all around the same size
• Blisters that ooze pus when they break
• Crusty skin forming over older blisters
• A cold sore above the upper lip
• High fever and chills
• A general unwell feeling and malaise
• Swollen lymph glands
  

Meanwhile, the symptoms of moderate-to-severe eczema in kids include:

• Dry, flaky skin that can appear pink, red, purple, brown, or gray, depending on skin tone
• Itchiness that is often extreme or severe but not usually intensely painful (though scratching can cause the area to be tender)
• Skin patches that may be thicker or discolored
• A rash that can have small bumps but doesn’t usually come with blisters of any kind
• No fever, chills, or other flu-like symptoms

If you suspect your child has eczema herpeticum or they develop a cold sore, call their pediatrician or pediatric dermatologist right away. You may need to go to your nearest urgent care or emergency room, depending on the severity and location of the rash, so antiviral medication can be prescribed as soon as possible.

Refrain from using any topical steroids you might have bought or been prescribed in the past, as they don’t work for eczema herpeticum and can actually do more harm than good.

“Topical steroids can promote the spread of infection on the skin,” says Dr. Wright, who is also chair of the American Academy of Pediatrics section on dermatology. “If a herpes infection is suspected, it is important for the child to be seen promptly by a physician who can perform testing and initiate treatment with oral antiviral medication.”

Sometimes the infection can even spread to the eyes, which requires emergency medical treatment, according to Wright. “If there are lesions on the eyelids, the child should be seen urgently by an ophthalmologist, as herpes infection in the eye can be quite serious.”

A good defense can go a long way. Try these tips to prevent your child from catching HSV-1.

• If you get cold sores, don’t kiss any of your children with atopic dermatitis. (Note, too, that some cases of HSV-1 go unnoticed or undetected or are asymptomatic.)
• Avoid sharing cups, food, and utensils; bedding, towels, and washcloths; and lip balm, toothbrushes, and other personal care products that may come in contact with saliva, says Levine.
• If you have an active herpes outbreak or cold sore, try not to touch your active lesions.
• Wash your hands regularly if you have a cold sore or herpes outbreak, particularly if you’re around a child with eczema. Have your kids wash their hands regularly, too, especially if a family member, friend, teacher, or other close contact has a cold sore or known herpes outbreak.

In addition, make sure you’re treating and managing your child’s atopic dermatitis as much as possible, which can help prevent a herpes infection and its more serious complications. “If the skin barrier is intact, that can help decrease the risk of developing eczema herpeticum,” says Wright.

“Parents often focus on preventing itching, but maintaining healthy skin is also an important infection-prevention strategy,” says Levine. “Well-controlled eczema means fewer cracks in the skin, less inflammation, and a stronger barrier against viruses like HSV-1.”

Ideally, if your child does develop eczema herpeticum, they should be seen by a doctor the same day symptoms appear, says Levine.

“Early treatment with antiviral medication is highly effective and can help prevent serious complications,” says Levine, “particularly if the infection involves the eyes or becomes widespread.”