Management of Itch in Eczema Herpeticum

First-Line PRN Treatment for Itch

Sedating antihistamines provide the most effective symptomatic relief for pruritus in eczema herpeticum due to their sedative properties 1
Chlorphenamine (chlorpheniramine) 4-12 mg at night can be an alternative option 3
Non-sedating antihistamines have little to no value in controlling itch in atopic eczema and are not recommended as routine treatment 1, 2

Sedating antihistamines should primarily be used at night to avoid daytime sedation 1
Large doses of antihistamines may be required in children with severe itch 1

Cooling antipruritic lotions such as calamine or 1% menthol in aqueous cream can provide soothing relief as adjunctive therapy 3
Ichthammol (1% in zinc ointment) may be useful for lichenified areas 1
Coal tar solution (1%) can be considered but should be used cautiously 1

The primary treatment for eczema herpeticum is systemic antiviral therapy (acyclovir), which should be given early in the course of disease 1, 4
In ill, febrile patients, acyclovir should be administered intravenously rather than orally 1, 4
Systemic antibiotics should only be added when there is clinical evidence of bacterial superinfection 2, 4
Flucloxacillin is typically the first-line antibiotic for treating Staphylococcus aureus, the most common bacterial pathogen in superinfected eczema herpeticum 1, 4

Hydroxyzine is contraindicated during early pregnancy 5
In patients with hepatic impairment, avoid chlorphenamine and hydroxyzine in severe liver disease 5
For patients with renal impairment, the dose of hydroxyzine should be halved 5
Tachyphylaxis may develop with prolonged use of antihistamines, reducing their effectiveness over time 1

Assess response to antihistamine therapy within 48-72 hours 5
If inadequate response to one sedating antihistamine, consider switching to another as individual responses vary 3
Monitor for excessive sedation, especially in patients taking other CNS depressants 2
Ensure that the underlying eczema herpeticum is being appropriately treated with antiviral therapy 4