1030
Brief communications
Journal of the American Academy of Dermatology
Kaposi's varicelliform eruption complicating irritant contact dermatitis Greg S. Morganroth, M D , Sharon A. Glick, MD, Maritza I. Perez, MD, Frank M. Castiglione, Jr., MD, and Jean L. Bolognia, M D New Haven, Connecticut Kaposi's varicelliform eruption ( K V E ) is characterized by disseminated vesiculopustules and erosions secondary to herpes simplex virus (HSV), vaecinia, or coxsackie virus superimposed on a preexisting dermatosis. TM Eczema herpeticum is another term to describe this entity because the most common cause is H S V and the most common underlying skin disease is atopic dermatitis. 2 K V E has also been described in association with Darier's disease, 4"6 benign familial pemphigus, 7 pemphigus foliaceus, 8 cutaneous T-cell lymphoma, t, 9 S4zary syndrome] ~ Wiskott-Aldrich syndrome, 3 seborrheic dermatitis, 3 ichthyosis vulgaris, 11 and congenital ichthyosiform erythroderma. 2'3 In addition, herpetic K V E has recently been reported in association with more acute skin disturbances such as healing second-degree burns, ~2 traumatic facial abrasions,13 and autologous skin grafting, t4 W e report a case of K V E in a young man that corresponded to areas in which vigorous cleansing with an abrasive cleanser had produced an irritant dermatitis. CASE REPORT
A 19-year-old man had a rapidly progressing vesiculopustular eruption on his face, neck, and antecubttal fossae (Fig. i). Approximately 10 days earlier, the patient began to use an abrasive cleanser (Mary Kay Buffing Cream), which contains polyethylene beads, on his face, neck, trunk, and arms. Vigorous scrubbing for 2 days produced an erythematous dermatitis on his face and neck and in his antecubital fossae; the facial inflammation was further aggravated by shaving. A vitamin A cream v~as applied twice daily for two days and provided no relief of symptoms. Five days before he came for treatment, fever, sore throat, cervical lymphadenopathy, malaise, and diarrhea developed. Oral penicillin was prescribed for presumptive streptococcal pharyngitis and hydrocortiFrom the Department of Dermatology, Yale University School of Medicine. Reprint requests: Grog S. Morganroth, MD, Department of Dermatology, Yate University School of Medicine, 333 Cedar St., New Haven, CT 06510. 16/54/39641
Fig. 1. Crusted lesions of Kaposi's varicelliform eruption after 7 days of intravenous acyclovir. sone 1.0% cream was applied to the cheeks and antecubital fossae. Two days later a burning sensation developed on the right side of his face and in botb antecubital fossae. This was followed by a painful, weeping, vesicular eruption in the same areas. The patient also had persistent tearing, a painful gritty sensation, and photophebia of the right eye. He denied a history of HSV infection, risk factors for human immunodeficiency virus (HIV), or a personal or family history of skin disease or atopy. His girlfriend had a history of recurrent labial HSV and reportedly had an active lesion during the preceding week. Examination revealed numerous, 2 to 3 ram, tense, umbilicated vesicles', pustules, and erosions on the face bilaterally, the right ear, the neck, the trunk, and in the antecubitat fossae. On the right side of the face and in the left antecubital fossa, the lesions had become confluent and eroded. Involvement of the right upper and lower eyelids was accompanied by periorbital edema. The right conjunctiva was injected and continuous tearing was present. Slit-lamp examination revealed pseudodendrite formation on the right cornea that was fluorescein-dye negative. Cervical lymphadenopathy was present. A Tzanck smear showed multinucleated giant cells consistent with a herpesvirus infection, and a test for HIV antibody was negative. Initial therapy consisted of intravenous acyclovir, 10 mg/kg every 8 hours; oral dicloxacillin, 250 mg every 6 hours; warm compresses with aluminum acetate solution; mupirocin ointment; and erythromycin ophthalmic ointment. The next day a direct
Volume 27 Number 6, Part 1 December 1992
fluorescent antibody test on vesicle fluid was positive for human herpesvirus type 1. This result was confirmed by viral culture. Repeat ophthalmic examination revealed corneal dendrite formations that were fluorescein-positire. Treatment with trifluridine 1% and homatropine hydrobromide 5% ophthalmic solutions was begun. After 8 days, all lesions had crusted, and the keratitis had improved significantly. Lichenification became apparent as the herpetic lesions resolved in the right antecubital fossa. The patient was discharged with a regimen of oral acyclovir and oral dicloxacillin. Two weeks later, there was complete resolution of the eruption but moderate facial scarring remained. Patch testing with the buffing cream and a standard fragrance mixture showed no reaction at 48 hours. An open use test with twice-daily application of the buffing cream reproduced the dermatitis on the inner arm at 72 hours. DISCUSSION The abrasive cleanser-induced dermatitis provided an explanation for the atypical distribution of K V E in this patient. This cleansing product contained polyethylene beads as well as several detergents (cocoamphodiacetate, lauramide DEA, and sodium laureth sulfate). Although vigorous rubbing with the beads alone could have produced the dermatitis, the detergents m a y have been a contributing factor. Patch testing in six volunteers produced one irritant reaction. A second unusual feature in this patient was the associated herpes keratitis, a phenomenon observed in only 5 of 85 patients with K V E in two previous series, z, 15 In patients with chronic skin disease, intrinisic defects in humoral 1, 9 or cellular 9 immunity and drug-induced immunosuppression 1, 2, 8, 9 have been implicated as primary factors in the pathogenesis of KVE. A n additional factor in the spread of herpetic lesions, especially in immunocompetent persons, is the presence of breaks in the epidermal barri-
Brief communications
1031
er.5, 6, ~2-14 Irritant contact dermatitis should be included in the list of skin conditions associated with KVE and should be considered when there is an atypical distribution of lesions. REFERENCES
1. Segal R J, Watson W. Kaposi's varicelliform eruption in mycosis fungoides.Arch Dermatol 1978;114:1067-9. 2. Bork K, Brguninger W. Increasing incidence of eczema herpeticum: analysisof 75 cases. J AM ACADDERMATOL 1988;16:1024-9. 3. Wheeler CE, AbeleDC. Eczema herpeticum,primary and recurrent. Arch Dermatol 1966;93:162-73. 4. Higgins PG, Crow KD. Recurrent Kaposi's varicellfform eruption in Darier's disease. Br J Dermatol 1973;88:391-4. 5. Fisher BK, Kibrick S. Primary herpes in an adult with Darier's disease.Arch Dermatol 1963;87:729-31. 6. yon Weiss JF, Kibrick S, Lever WF. Eczema herpeticum as complication of Darier's disease. Ann Intern Med 1965;62:1293-6. 7. Otsuka F, Niimura N, Harada S, et al. Generalizedherpes simplex complicatingHailey-Hailey'sdisease. J Dermatol (Tokyo) 1981;8:63-8. 8. SilversteinEH, Burnett JW. Kaposi's varicelliformeruption complicating pemphigus foliaeeus. Arch Dermatol 1967;95:214-6. 9. Taulbee K, Johnson S, Disseminated cutaneous herpes simplex infection in cutaneous T-cell lymphoma. Arch Dermatol 1981;117:114-5. 10. Scully RE, Galdabini JJ, MeNeely BU. Case 37-1975, Case records of Massachusetts General Hospital. Weekly clinicopathologicexercises. N Engl J Med 1975;293:598603. 11. VerbovJ, Munro DD, Miller A. Recurrent eczemaherpeticum associatedwith ichthyosisvulgaris. Br J Dermatol 1972;86:638-40. 12. Nishimura M, MaekawaM, Hino Y, et al. Kaposi's varicelliformeruption:developmentin a patient with a healing second-degreeburn. Arch Dermatol 1984;120:799-800. 13. GrossmanJA, BergerR, Hoehn RJ. Kaposi'svaricelliform eruption complicatinglocal facial trauma. Plast Reconstr Surg 1975;55:625-7. 14. MandersSM, ChettyBV.Eczemaherpeticum occurringin autografted skin.J AM ACADDERMATOL1991;24:509-10. 15. FivensonDP, Breneman DL, Wander AH. Kaposi's varicell/form eruption: absence of ocular involvement. Arch Dermatol 1990;126:1037-9.
Brief communications
Journal of the American Academy of Dermatology
Kaposi's varicelliform eruption complicating irritant contact dermatitis Greg S. Morganroth, M D , Sharon A. Glick, MD, Maritza I. Perez, MD, Frank M. Castiglione, Jr., MD, and Jean L. Bolognia, M D New Haven, Connecticut Kaposi's varicelliform eruption ( K V E ) is characterized by disseminated vesiculopustules and erosions secondary to herpes simplex virus (HSV), vaecinia, or coxsackie virus superimposed on a preexisting dermatosis. TM Eczema herpeticum is another term to describe this entity because the most common cause is H S V and the most common underlying skin disease is atopic dermatitis. 2 K V E has also been described in association with Darier's disease, 4"6 benign familial pemphigus, 7 pemphigus foliaceus, 8 cutaneous T-cell lymphoma, t, 9 S4zary syndrome] ~ Wiskott-Aldrich syndrome, 3 seborrheic dermatitis, 3 ichthyosis vulgaris, 11 and congenital ichthyosiform erythroderma. 2'3 In addition, herpetic K V E has recently been reported in association with more acute skin disturbances such as healing second-degree burns, ~2 traumatic facial abrasions,13 and autologous skin grafting, t4 W e report a case of K V E in a young man that corresponded to areas in which vigorous cleansing with an abrasive cleanser had produced an irritant dermatitis. CASE REPORT
A 19-year-old man had a rapidly progressing vesiculopustular eruption on his face, neck, and antecubttal fossae (Fig. i). Approximately 10 days earlier, the patient began to use an abrasive cleanser (Mary Kay Buffing Cream), which contains polyethylene beads, on his face, neck, trunk, and arms. Vigorous scrubbing for 2 days produced an erythematous dermatitis on his face and neck and in his antecubital fossae; the facial inflammation was further aggravated by shaving. A vitamin A cream v~as applied twice daily for two days and provided no relief of symptoms. Five days before he came for treatment, fever, sore throat, cervical lymphadenopathy, malaise, and diarrhea developed. Oral penicillin was prescribed for presumptive streptococcal pharyngitis and hydrocortiFrom the Department of Dermatology, Yale University School of Medicine. Reprint requests: Grog S. Morganroth, MD, Department of Dermatology, Yate University School of Medicine, 333 Cedar St., New Haven, CT 06510. 16/54/39641
Fig. 1. Crusted lesions of Kaposi's varicelliform eruption after 7 days of intravenous acyclovir. sone 1.0% cream was applied to the cheeks and antecubital fossae. Two days later a burning sensation developed on the right side of his face and in botb antecubital fossae. This was followed by a painful, weeping, vesicular eruption in the same areas. The patient also had persistent tearing, a painful gritty sensation, and photophebia of the right eye. He denied a history of HSV infection, risk factors for human immunodeficiency virus (HIV), or a personal or family history of skin disease or atopy. His girlfriend had a history of recurrent labial HSV and reportedly had an active lesion during the preceding week. Examination revealed numerous, 2 to 3 ram, tense, umbilicated vesicles', pustules, and erosions on the face bilaterally, the right ear, the neck, the trunk, and in the antecubitat fossae. On the right side of the face and in the left antecubital fossa, the lesions had become confluent and eroded. Involvement of the right upper and lower eyelids was accompanied by periorbital edema. The right conjunctiva was injected and continuous tearing was present. Slit-lamp examination revealed pseudodendrite formation on the right cornea that was fluorescein-dye negative. Cervical lymphadenopathy was present. A Tzanck smear showed multinucleated giant cells consistent with a herpesvirus infection, and a test for HIV antibody was negative. Initial therapy consisted of intravenous acyclovir, 10 mg/kg every 8 hours; oral dicloxacillin, 250 mg every 6 hours; warm compresses with aluminum acetate solution; mupirocin ointment; and erythromycin ophthalmic ointment. The next day a direct
Volume 27 Number 6, Part 1 December 1992
fluorescent antibody test on vesicle fluid was positive for human herpesvirus type 1. This result was confirmed by viral culture. Repeat ophthalmic examination revealed corneal dendrite formations that were fluorescein-positire. Treatment with trifluridine 1% and homatropine hydrobromide 5% ophthalmic solutions was begun. After 8 days, all lesions had crusted, and the keratitis had improved significantly. Lichenification became apparent as the herpetic lesions resolved in the right antecubital fossa. The patient was discharged with a regimen of oral acyclovir and oral dicloxacillin. Two weeks later, there was complete resolution of the eruption but moderate facial scarring remained. Patch testing with the buffing cream and a standard fragrance mixture showed no reaction at 48 hours. An open use test with twice-daily application of the buffing cream reproduced the dermatitis on the inner arm at 72 hours. DISCUSSION The abrasive cleanser-induced dermatitis provided an explanation for the atypical distribution of K V E in this patient. This cleansing product contained polyethylene beads as well as several detergents (cocoamphodiacetate, lauramide DEA, and sodium laureth sulfate). Although vigorous rubbing with the beads alone could have produced the dermatitis, the detergents m a y have been a contributing factor. Patch testing in six volunteers produced one irritant reaction. A second unusual feature in this patient was the associated herpes keratitis, a phenomenon observed in only 5 of 85 patients with K V E in two previous series, z, 15 In patients with chronic skin disease, intrinisic defects in humoral 1, 9 or cellular 9 immunity and drug-induced immunosuppression 1, 2, 8, 9 have been implicated as primary factors in the pathogenesis of KVE. A n additional factor in the spread of herpetic lesions, especially in immunocompetent persons, is the presence of breaks in the epidermal barri-
Brief communications
1031
er.5, 6, ~2-14 Irritant contact dermatitis should be included in the list of skin conditions associated with KVE and should be considered when there is an atypical distribution of lesions. REFERENCES
1. Segal R J, Watson W. Kaposi's varicelliform eruption in mycosis fungoides.Arch Dermatol 1978;114:1067-9. 2. Bork K, Brguninger W. Increasing incidence of eczema herpeticum: analysisof 75 cases. J AM ACADDERMATOL 1988;16:1024-9. 3. Wheeler CE, AbeleDC. Eczema herpeticum,primary and recurrent. Arch Dermatol 1966;93:162-73. 4. Higgins PG, Crow KD. Recurrent Kaposi's varicellfform eruption in Darier's disease. Br J Dermatol 1973;88:391-4. 5. Fisher BK, Kibrick S. Primary herpes in an adult with Darier's disease.Arch Dermatol 1963;87:729-31. 6. yon Weiss JF, Kibrick S, Lever WF. Eczema herpeticum as complication of Darier's disease. Ann Intern Med 1965;62:1293-6. 7. Otsuka F, Niimura N, Harada S, et al. Generalizedherpes simplex complicatingHailey-Hailey'sdisease. J Dermatol (Tokyo) 1981;8:63-8. 8. SilversteinEH, Burnett JW. Kaposi's varicelliformeruption complicating pemphigus foliaeeus. Arch Dermatol 1967;95:214-6. 9. Taulbee K, Johnson S, Disseminated cutaneous herpes simplex infection in cutaneous T-cell lymphoma. Arch Dermatol 1981;117:114-5. 10. Scully RE, Galdabini JJ, MeNeely BU. Case 37-1975, Case records of Massachusetts General Hospital. Weekly clinicopathologicexercises. N Engl J Med 1975;293:598603. 11. VerbovJ, Munro DD, Miller A. Recurrent eczemaherpeticum associatedwith ichthyosisvulgaris. Br J Dermatol 1972;86:638-40. 12. Nishimura M, MaekawaM, Hino Y, et al. Kaposi's varicelliformeruption:developmentin a patient with a healing second-degreeburn. Arch Dermatol 1984;120:799-800. 13. GrossmanJA, BergerR, Hoehn RJ. Kaposi'svaricelliform eruption complicatinglocal facial trauma. Plast Reconstr Surg 1975;55:625-7. 14. MandersSM, ChettyBV.Eczemaherpeticum occurringin autografted skin.J AM ACADDERMATOL1991;24:509-10. 15. FivensonDP, Breneman DL, Wander AH. Kaposi's varicell/form eruption: absence of ocular involvement. Arch Dermatol 1990;126:1037-9.
