over an infection) with Staphylococcus aureus or Streptococcus pyogenes may be present S pyogenes by itself may cause a secondary infection in an atopic child that resembles eczema herpeticum, presenting with fever, cellulitis, and clusters of pustular skin lesions The decision to admit to hospital should be determined by the degree of toxicity While patients may require in-hospital care for intravenous hydration or intravenous antibiotic therapy to address widespread bacterial infection or bacteremia, selected nontoxic patients with limited disease may be successfully managed in the outpatient setting, as long as patients are followed closely and reconsidered for admission if they not respond adequately or worsen clinically When a patient is suspected of having KVE, the initial history taking should identify the existence of an underlying primary skin disease history, its usual sites of anatomic involvement, and the suspected viral agent— herpes simplex, enterovirus, vaccinia, or varicella zoster Recommended diagnostic studies include polymerase chain reaction (PCR) assay, direct fluorescent antibody testing, or viral culture for herpes simplex virus, varicella zoster virus, and if suspected, enteroviral PCR or culture Vaccinia virus may be considered in the appropriate exposure context Bacterial skin culture and blood culture for bacteria may be obtained if a bacterial superinfection is suspected Recommended therapy involves empiric antiviral treatment with activity against herpes simplex, such as acyclovir or valacyclovir Empiric antistaphylococcal and antistreptococcal coverage may be considered if significant serous crusting is present, and especially if the child is febrile or ill appearing The optimal agent depends on local antibiotic resistance patterns but will most likely include clindamycin, a first-generation cephalosporin such as cephalexin or cefazolin, a penicillinase-resistant agent such as oxacillin or nafcillin, or in more severe cases, vancomycin If trimethoprim-sulfamethoxazole is used, it may need to be combined with another agent to provide adequate coverage for streptococci Empiric antiviral therapy for eczema herpeticum reduces the length of hospital stay (LOS) when started promptly As the antiviral medications are both relatively safe and inexpensive, a low threshold for starting these agents is recommended In contrast, empiric systemic antibiotic therapy reduces LOS only when there is bacteremia