Infected Eczema

Comments from Expert Advisory Group

Patients should be encouraged to use emollients regularly
Emollients help to reduce dryness, which can improve the barrier function of the skin, easing itch and pain while reducing exposure to bacteria and sensitising antigens
Signs and symptoms of secondary bacterial infection of eczema can include:
- Weeping
- Pain
- Crusting of lesions (similar in appearance to impetigo)
- Pustules
- Rapidly worsening eczema
- Fever
- Malaise
Staphylococcus aureus is the most common bacteria implicated in infection
In patients who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema
Evidence suggests there is a limited benefit in using combination topical antibiotic/corticosteroid preparations compared with topical corticosteroids alone
Swabs are not indicated unless in cases of treatment failure or atypical bacterial cause suspected
Reserve topical antimicrobials for localised infections
To reduce the risk of antimicrobial resistance:
- Topical antimicrobials and oral antimicrobials should not be used concomitantly
- Topical antimicrobials should be used for a limited period (<2 weeks)
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staphylococcus aureus and is associated with persistent recurrent pustules and carbuncles or cellulitis. Send swabs for culture in these clinical scenarios. On rare occasions it causes more severe invasive infections, even in otherwise fit people. Risk factors include: nursing homes, contact sports, sharing equipment, poor hygiene and eczema.

Infected Eczema

Image source: Dermnet

eczemaimage

Eczema Herpeticum

Eczema herpeticum is a severe skin infection caused by the dissemination of the herpes simplex virus. It is characterised by:
- Areas of rapidly worsening and painful eczema
- Clustered blisters consistent with early-stage cold sores
- Punched-out erosions usually 1mm to 3mm in diameter, which are uniform in appearance. These may coalesce into larger areas of erosions
- Possible fever, distress or lethargy
It is a dermatological emergency, warranting same day referral to local dermatology department / hospital

Facial Eczema Herpeticum

Image Source: Dermnet

eczemaimage2

Eczema Herpeticum on the chest

Image Source: Dermnet

Infection Prophylaxis

Bleach Baths

Bleach baths are an option for infection prophylaxis
Limited evidence to support their use, however they are commonly used in practice
Should not be used during active infection
May reduce the bacterial load on the skin and contribute to reduced numbers of infections
To be used once or twice a week

Bleach Bath Recipe

Ingredients required

Milton Sterilising Fluid^®
- This is a form of bleach, containing 2% sodium hypochlorite
- Other bleaches can be used but they should be free of perfumes, colours and consist of 2% sodium hypochlorite

How to use a bleach bath

Fill bath with desired amount of warm water.
Add Milton Sterilising Fluid® to the bath and completely mix it in. You should aim to use 2mls of Milton Sterilising Fluid® for every litre of bath water. This is roughly half a cup (150mls) to a full adult bath tub (containing water to a depth of 10cm).
Soak in the bath water up to your neck for about 10 minutes. For smaller children, use a sponge or flannel to soak any dry and affected areas that are out of the water.
At the end of the bath, rinse well with fresh warm water (this could be done in the shower).
As soon as the bath is over, pat the skin dry. Do not rub as this may irritate the skin.
Immediately apply any prescribed emollients and other treatments.

Cautions

Never use undiluted bleach products directly on the skin
Avoid getting undiluted or diluted bleach into the eyes
Do not swallow bleach water
Avoid adding bleach to very hot water, as this may produce fumes
Bleach products may make the bath slippery
Bleach products will cause discolouration of clothing and towels, so avoid contact with items of clothing which may be affected and use white towels if possible

Treatment

Infected Eczema Treatment
Drug	Children's Dose	Adult Dose	Duration	Notes
1st choice option
Flucloxacillin	See flucloxacillin dosing table for children	500mg every 6 hours	7 days	Avoid in penicillin allergy To optimise absorption, take on an empty stomach (either 1 hour before food or 2 hours after).
2nd choice options
Cefalexin	See cefalexin dosing table for children	500mg every 12 hours	7 days	Cephalosporins should not be used in severe penicillin allergy.
Clarithromycin	See clarithromycin dosing table for children	250mg every 12 hours (can be increased if necessary in severe infection to 500mg every 12 hours)	7 days	Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy.
1st choice option in pregnant, penicillin allergic patients
Clindamycin		300mg every 6 hours	7 days	Caution: risk of C. difficile.
Topical Treatment (Reserve for localised infections)
Fusidic Acid	Topically to affected areas every 8 hours		5-7 days

Patient Information

Safe Prescribing (visit the safe prescribing page)

Dosing in children quick reference dosage/weight guide
Clarithromycin and other macrolides warning
Penicillin allergy – tips on prescribing in penicillin allergy
Renal impairment dosing table
Safety in Pregnancy and Lactation
Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed November 2022