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Infected eczema

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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

Treatment	Antibiotic, dosage and course length
For secondary bacterial infection of eczema in people who are not systemically unwell	Do not routinely offer either a topical or oral antibiotic.
First-choice topical if a topical antibiotic is appropriate	Fusidic acid 2%: Apply three times a day for 5 to 7 days. For localised infections only. Extended or recurrent use may increase the risk of developing antimicrobial resistance.
First-choice oral if an oral antibiotic is appropriate	Flucloxacillin: 500 mg four times a day for 5 to 7 days.
Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable	Clarithromycin: 250 mg twice a day for 5 to 7 days. The dosage can be increased to 500 mg twice a day for severe infections.
Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable, and the person is pregnant	Erythromycin: 250 mg to 500 mg four times a day for 5 to 7 days.
If meticillin-resistant Staphylococcus aureus is suspected or confirmed	Consult a microbiologist.

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

Treatment	Antibiotic, dosage and course length
For secondary bacterial infection of eczema in people who are not systemically unwell	Do not routinely offer either a topical or oral antibiotic.
First-choice topical if a topical antibiotic is appropriate	Fusidic acid 2%: Apply three times a day for 5 to 7 days. For localised infections only. Extended or recurrent use may increase the risk of developing antimicrobial resistance.
First-choice oral if an oral antibiotic is appropriate	Flucloxacillin (oral solution or capsules): 1 month to 1 year: 62.5 mg to 125 mg four times a day for 5 to 7 days. 2 years to 9 years: 125 mg to 250 mg four times a day for 5 to 7 days. 10 years to 17 years: 250 mg to 500 mg four times a day for 5 to 7 days.
Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable	Clarithromycin: 1 month to 11 years: under 8 kg: 7.5 mg/kg twice a day for 5 to 7 days 8 kg to 11 kg: 62.5 mg twice a day for 5 to 7 days 12 kg to 19 kg: 125 mg twice a day for 5 to 7 days 20 kg to 29 kg: 187.5 mg twice a day for 5 to 7 days 30 kg to 40 kg: 250 mg twice a day for 5 to 7 days. 12 years to 17 years: 250 mg twice a day for 5 to 7 days. The dosage can be increased to 500 mg twice a day for severe infections.
Alternative oral antibiotic if the person has a penicillin allergy or flucloxacillin is unsuitable, and the person is pregnant	Erythromycin: 8 years to 17 years: 250 mg to 500 mg four times a day for 5 to 7 days.
If meticillin-resistant Staphylococcus aureus is suspected or confirmed	Consult a local microbiologist.

Reference:

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Infected eczema

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