Atopic eczema, infected (management)

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Objectives

The aim of the guideline is to aid in the management of infected eczema in children.

Scope

This guidance should be followed by healthcare professionals involved in the care of children with infected eczema.

Atopic Eczema is associated with an impaired skin barrier, leading to dryness, susceptibility to irritants and allergens coming into contact with the skin and secondary infection with organisms. People with atopic eczema carry S. aureus in about 90% of affected areas and the density of S.aureus increases with the severity of the eczema. While carriage of S.aureus does not equate to infection, swabs from areas of erythema, crusting, weeping and oozing often produce heavy growth on culture and in these circumstances the bacteria contribute to exacerbation of the eczema. It is therefore important to treat both the eczema and secondary infection in a child with infected atopic eczema. Topical steroids alone reduce skin colonisation by S. aureus but if the skin is clinically infected oral antibiotic or topical antimicrobial /antibiotic should be used in addition to the topical steroid. Infected eczema should not be managed with antibiotics alone as this does not manage the eczema flare, fails to restore the skin barrier and prolongs morbidity/ duration of admission.

Investigation

A Bacterial skin swab should always be taken before initiation of oral antibiotics.
If recurrent infections are experienced the anterior nares should also be swabbed.
Viral swab should be taken if there are monomorphic erosions or recent herpetic infection in a relative.

Managing the eczema

1. Bathing

A bath emollient with an antiseptic additive such as Dermol 600® should added to the bath water.

2. Emollients

Ensure that the child does not use tubs of creams/ointments from home as may have become contaminated by S. aureus.

Prescribe the child’s usual emollient to be applied 3-4 times daily. If the child’s skin is dry increase the greasiness to an ointment. Parents should be advised to transfer a small amount onto a saucer or piece of kitchen towel with a spatula/spoon (not hand) and throw out what is left when finished applying rather than putting back into the tub.

3. Topical corticosteroids

Applied once or twice daily to all active areas until redness and itching have cleared (usually 5 days on face and 7-10 days on body).

Face: 1% hydrocortisone ointment or Daktacort oint. ® should be used b.d if mildly active. Trimovate® or Eumovate® b.d if very red, oozing or crusted.

Body: Moderate potency (Eumovate®, Modrasone® or Trimovate®) if mildly active. Potent steroid/antimicrobial (Betnovate C® or Synalar C®) if very red, oozing or crusted.

Parents should then continue to treat chronic patches of eczema twice weekly to prevent flares.

Managing Bacterial Infection

Protocol for managing bacterial skin infections as per GG&C guidelines with oral or IV antibiotic as indicated by clinical severity.

Herpetic superinfection

Recognised by widespread monomorphic round vesicles or erosions. This often leads to an acute deterioration in the eczema and is commonly accompanied by secondary bacterial infection which can delay diagnosis and response to treatment. Therefore, it is important that the viral and bacterial infection and the eczema flare are managed in tandem.

Treat with oral or IV acyclovir as indicated by clinical severity.
Urgent Ophthalmology review if near to eye.

Once Aciclovir (and antibiotics if secondary bacterial infection present) has been initiated (2 doses given) then eczema should be managed as above including application of topical corticosteroids +/- antimicrobial to areas of eczema. Delay between Initiation of Aciclovis/Antibiotics and steroid application should not be more than two doses.

Editorial Information

Last reviewed: 01 June 2015

Next review: 01 June 2017

Author(s): Paula Beattie

Approved By: Clinical Effectiveness

Reviewer Name(s): PERC