An 11-month-old boy presented with a two-day history of fever and rash. He had atopic dermatitis (AD) since the age of 2 months, poorly controlled with low-potency topical corticosteroids (TCs). The physical examination revealed multiple erythematous papules and vesicles with crusting over the perioral region, trunk, and extremities, overlapping with eczematous areas (Figs. 1–3). Acyclovir was initiated for suspected eczema herpeticum; however, viral swabs were positive for Coxsackievirus A6 (CA6) by RT-PCR, confirming eczema coxsackium (EC). Acyclovir was discontinued, and supportive care with emollients and antipyretics was maintained. At the two-week follow-up, the lesions had resolved without secondary infection. Atopic dermatitis remained controlled with medium-potency TC.

Figure 1.

Multiple erythematous vesicles, erosions, and crusted papules on the face and trunk with background eczematous skin, two days after rash onset.

Figure 2.

Generalized papulovesicular eruption with confluence on the trunk, two days after rash onset.

Figure 3.

Vesicles and erythematous macules on the soles, consistent with atypical hand, foot, and mouth disease distribution, two days after rash onset.

Atopic dermatitis is a chronic inflammatory skin disorder associated with increased susceptibility to infection. Eczema coxsackium, an atypical form of hand-foot-mouth disease (HFM) caused mainly by CA6, preferentially affects areas where the skin barrier is compromised. Lesions are typically vesicular or bullous over active or inactive eczema. Unlike classic HFM, which involves the palms, soles, and oral mucosa, EC presents with more extensive polymorphic eruptions involving the face and trunk. Recent studies report increasing atypical HFM outbreaks linked to CA6 worldwide, underscoring the need for awareness of this entity to prevent misdiagnosis and unnecessary antiviral or antibiotic therapy.1–3