What is the treatment for eczema with an infected wound?

Treatment of Infected Eczema

For eczema with secondary bacterial infection, continue topical corticosteroids as the mainstay of treatment while simultaneously initiating systemic antibiotics—specifically flucloxacillin as first-line oral therapy for Staphylococcus aureus, the most common pathogen. 1

Immediate Assessment and Recognition

Look for these specific signs of bacterial superinfection on eczematous skin:

• Crusting or weeping lesions 2
• Pustules or increased exudate 1
• Sudden worsening of previously stable eczema 2

Critical distinction: If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum (herpes simplex superinfection)—this is a medical emergency requiring immediate acyclovir. 1

Primary Treatment Algorithm

Step 1: Maintain Topical Corticosteroid Therapy

Do not discontinue topical corticosteroids when infection is present. 1 This is a common pitfall that leads to treatment failure.

• Apply topical corticosteroids twice daily to affected areas using the least potent preparation that controls symptoms 1
• The combination of appropriate systemic antibiotics with continued topical corticosteroids is the correct approach 1
• Topical corticosteroid-antibiotic combinations (fusidic acid-betamethasone or mupirocin-hydrocortisone) are extremely useful when staphylococcal infection is suspected 3

Step 2: Initiate Systemic Antibiotic Therapy

First-line treatment: Flucloxacillin orally for Staphylococcus aureus 1

Alternative options for hospitalized patients or severe infections:

• Clindamycin 600 mg IV/PO three times daily (good activity against staphylococci, streptococci, and anaerobes) 2
• Vancomycin IV (for MRSA or severe infections) 2
• Linezolid 600 mg PO/IV twice daily 2

Important resistance considerations: Recent data shows MRSA is completely resistant to penicillin, erythromycin, and cefuroxime, with high resistance to clindamycin (82.35%). 4 Linezolid and vancomycin maintain high sensitivity including against multidrug-resistant bacteria. 4

Step 3: Consider Topical Antibiotic-Corticosteroid Combinations

For minor or localized infected eczema:

• Fusidic acid 2% plus betamethasone 0.1% cream applied twice daily shows superior clinical effect with low resistance rates (9% for fusidic acid vs 21% for gentamicin) 5
• Mupirocin 2% topical ointment for secondarily infected skin lesions such as eczema 2

Caveat: Topical antibiotics alone add little benefit to what topical corticosteroids achieve in infected eczema not requiring systemic therapy. 6 The combination products are preferred over topical antibiotics alone.

Essential Adjunctive Measures

Continue these throughout treatment:

• Liberal emollient application, especially after bathing, to provide a surface lipid film 1
• Use soap-free cleansers and avoid irritants 1
• Keep nails short to minimize excoriation 2

Special Situations

Pediatric Patients

• Mupirocin 2% topical ointment for minor secondarily infected lesions 2
• Clindamycin 10-13 mg/kg/dose IV every 6-8 hours if hospitalized (only if clindamycin resistance rate is low, <10%) 2
• Avoid tetracyclines in children <8 years of age 2

Eczema Herpeticum (Medical Emergency)

• Initiate oral acyclovir early in the disease course 1
• For ill, feverish patients, administer acyclovir intravenously 1
• Send viral swab for electron microscopy confirmation 2

Treatment Duration and Monitoring

• Continue therapy for 7-14 days based on clinical response 2
• Bacteriological swabs are not routinely indicated but obtain them if patients fail to respond to treatment 2
• Reassess after 2-4 days to confirm clinical improvement 5

Critical Pitfalls to Avoid

• Never discontinue topical corticosteroids during infection treatment—they remain the primary therapy when appropriate systemic antibiotics are given concurrently 1
• Avoid penicillin monotherapy—it is not recommended due to widespread resistance 4
• Do not use topical antibiotics alone for infected eczema requiring systemic therapy—they provide minimal additional benefit over corticosteroids 6
• Do not delay treatment if eczema herpeticum is suspected—this is a dermatologic emergency 1