What is the treatment for infected dermatitis?

Treatment of Infected Dermatitis

For infected dermatitis, systemic antistaphylococcal antibiotics should be reserved for patients with clinical evidence of bacterial infection (purulent exudate, pustules), while topical antibiotics can be used for localized superficial infections. 1

Identifying True Infection vs. Colonization

The key clinical challenge is distinguishing active infection from colonization or inflammation alone:

• Clinical signs suggesting bacterial infection include purulent exudate and pustules on examination 1
• Crusting alone may be present in either infection or active dermatitis and is not diagnostic 1
• Staphylococcus aureus colonizes >90% of dermatitis patients but most do not require antibiotic treatment 1
• Swab the affected area for culture and sensitivity testing when infection is suspected, particularly for recurrent or non-responsive cases 1

Treatment Algorithm

For Clinically Infected Dermatitis:

Systemic antibiotics are warranted only in overtly infected patients 1:

• First-line: Cephalexin is the preferred systemic antibiotic due to its restricted spectrum targeting Gram-positive bacteria, with only 3% resistance rates in dermatitis patients 2
• Alternative systemic options include cefuroxime or amoxicillin-clavulanate (also 3% resistance) 2
• Avoid erythromycin, clindamycin, and fluoroquinolones as first-line due to higher resistance rates (21-23%) 2
• Continue standard dermatitis treatment concurrently, including topical corticosteroids 1

For localized superficial infections:

• Topical mupirocin cream three times daily is clinically equivalent to oral cephalexin and bacteriologically superior, with better patient preference 3
• Topical antibiotics should not be used prophylactically in non-infected dermatitis 1

For Specific Dermatitis Types:

Candidal involvement (diaper dermatitis):

• Add topical antifungal agents: clotrimazole, miconazole, or nystatin 4

Viral superinfection (eczema herpeticum):

• Systemic antiviral therapy is mandatory - this is a dermatologic urgency with historically 10-50% mortality if untreated 1
• Earlier acyclovir initiation decreases hospital length of stay 1

Critical Monitoring

When infection is suspected or documented:

• Check blood granulocyte counts, especially if receiving concomitant chemotherapy 1
• Obtain blood cultures if signs of sepsis/fever are present, particularly with low granulocyte counts 1
• Severe desquamation carries risk of septicemia 1

Common Pitfalls to Avoid

• Do not use antibiotics for colonized but non-infected dermatitis - colony counts return to baseline within days to weeks after discontinuation, and incomplete eradication increases resistance 1
• Avoid overuse of antiseptic creams, which can irritate skin 1
• Do not use high-potency topical corticosteroids in occluded areas (like diaper region) due to increased absorption 4
• Topical antibiotics should not be used prophylactically 1

Adjunctive Measures

For radiation dermatitis with suspected infection:

• Antibacterial moisturizers (chlorhexidine or triclosan-based) may be used occasionally if anti-infective measures are desired 1
• Silver sulfadiazine or beta glucan cream can be applied after radiotherapy in the evening 1