Infected eczema

• cutaneous infection occurs secondary to factors such as reduced immunity and reduced barrier function of skin:
  • viral infections - herpes simplex causing eczema herpeticum; warts; molluscum contagiosum;
  • bacterial infection for example colonisation of epidermis by staphylococcal aureus; frank staphylococcal infection such as impetigo

Managing secondary bacterial infections of eczema
Treatment

• in people with symptoms or signs of cellulitis - then see link below
• manage underlying eczema and flares with treatments such as emollients and topical corticosteroids, whether antibiotics are offered or not

Clinicians must be aware that:

• the symptoms and signs of secondary bacterial infection of eczema can include: weeping, pustules, crusts, no response to treatment, rapidly worsening eczema, fever and malaise
• not all eczema flares are caused by a bacterial infection, so will not respond to antibiotics, even if weeping and crusts are present
• eczema is often colonised with bacteria but may not be clinically infected
• eczema can also be infected with herpes simplex virus (eczema herpeticum)

Do not routinely take a skin swab for microbiological testing in people with secondary bacterial infection of eczema at the initial presentation

In people who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema. Take into account:

• the evidence, which suggests a limited benefit with antibiotics in addition to topical corticosteroids compared with topical corticosteroids alone
• the risk of antimicrobial resistance with repeated courses of antibiotics
• the extent and severity of symptoms or signs
• the risk of developing complications, which is higher in people with underlying conditions such as immunosuppression

If an antibiotic is offered to people who are not systemically unwell with a secondary bacterial infection of eczema, when choosing between a topical or oral antibiotic, take into account:

• their preferences (and those of their parents and carers as appropriate) for topical or oral administration
• the extent and severity of symptoms or signs (a topical antibiotic may be more appropriate if the infection is localised and not severe; an oral antibiotic may be more appropriate if the infection is widespread or severe)
• possible adverse effects
• previous use of topical antibiotics because antimicrobial resistance can develop rapidly with extended or repeated use

In people who are systemically unwell, offer an oral antibiotic for secondary bacterial infection of eczema.

Reassessment

Reassess people with secondary bacterial infection of eczema if:

• they become systemically unwell or have pain that is out of proportion to the infection
• their symptoms worsen rapidly or significantly at any time
• their symptoms have not improved after completing a course of antibiotics

When reassessing people with secondary bacterial infection of eczema, take account of:

• other possible diagnoses, such as eczema herpeticum
• any symptoms or signs suggesting a more serious illness or condition, such as cellulitis, necrotising fasciitis or sepsis
• previous antibiotic use, which may have caused resistant bacteria

For people with secondary bacterial infection of eczema that is worsening or has not improved as expected, consider sending a skin swab for microbiological testing

For people with secondary bacterial infection of eczema that recurs frequently:

• send a skin swab for microbiological testing and
• consider taking a nasal swab and starting treatment for decolonisation

If a skin swab has been sent for microbiological testing:

• review the choice of antibiotic when results are available and
• change the antibiotic according to results if symptoms are not improving, using a narrow-spectrum antibiotic if possible

Choice of antibiotics for adults aged 18 years and over

Choice of antibiotics for children and young people aged from 1 month to under 18 years

Reference:

1. NICE (March 2021). Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing
2. Public Health England (June 2021). Managing common infections: guidance for primary care