What additional treatment can be considered for a 13-year-old with eczema (atopic dermatitis) and a skin lesion on the ear with broken skin, scabbing, and mild improvement with hydrocortisone (corticosteroid) twice daily?

Treatment Escalation for Eczema with Signs of Secondary Infection

Given the broken skin, scabbing, and reported oozing, this patient likely has secondarily infected eczema and should be started on oral flucloxacillin while simultaneously escalating to a more potent topical corticosteroid than hydrocortisone. 1, 2

Immediate Management Steps

Add Antibiotic Coverage

• Start oral flucloxacillin as the first-line antibiotic for presumed Staphylococcus aureus infection, which is the most common pathogen in infected eczema 1
• The presence of broken skin, scabbing, and oozing strongly suggests secondary bacterial infection, which is critical to treat in atopic dermatitis 1
• Alternative antibiotics include erythromycin if there is penicillin allergy or flucloxacillin resistance 1

Escalate Topical Corticosteroid Potency

• Switch from hydrocortisone (mild potency) to a moderate-potency topical corticosteroid such as mometasone furoate 0.1% ointment or fatty cream 2
• Moderate-potency topical corticosteroids result in significantly more patients achieving treatment success compared to mild preparations (52% versus 34% clearance rate) 3
• Hydrocortisone is a mild-potency steroid that may be insufficient for this presentation with broken skin and signs of infection 1, 2

Application Frequency

• Continue twice-daily application of the topical corticosteroid, as once-daily versus twice-daily application shows similar effectiveness, so maintaining the current frequency is appropriate 3
• Treatment should not be applied more than twice daily 1

Essential Adjunctive Measures

Emollient Therapy

• Apply fragrance-free emollients liberally to the entire body at least once daily, not just the affected ear, to restore skin barrier function 2
• Emollients are most effective when applied after bathing and provide a surface lipid film that retards evaporative water loss 1
• Consider urea- or glycerin-based moisturizers for enhanced barrier restoration 2

Bathing and Cleansing

• Use soap-free cleansers to avoid further barrier disruption 2
• Bathing is useful for both cleansing and hydrating the skin in most patients 1

Important Caveats

Monitoring for Infection

• Be vigilant for signs of eczema herpeticum (herpes simplex infection), which presents with multiple discrete vesicles and erosions and requires oral acyclovir 1
• The distinction between bacterial and viral superinfection is critical, as management differs significantly 1

Antibiotic Resistance Concerns

• While combined antibiotic/corticosteroid creams (such as fusidic acid with corticosteroid) can be effective, there is concern about emergence of antibiotic resistance with prolonged use 4
• Oral antibiotics are preferred over topical antibiotic/steroid combinations for overt secondary infection 1

Duration and Follow-up

• If there is no improvement after appropriate escalation of therapy, referral to a dermatologist should be considered 1
• Once the acute flare is controlled, consider stepping down to the least potent preparation required to maintain control 1

What NOT to Do

• Do not add oral antihistamines for routine itch control, as they have minimal benefit beyond sedation and should only be used short-term at night for severe pruritus 2
• Do not use non-sedating antihistamines, as they have little or no value in atopic eczema 1, 2
• Avoid wool clothing next to the skin; cotton clothing is more comfortable and recommended 1