What is the recommended treatment approach for a patient with severe eczema and concurrent cellulitis, considering the use of systemic corticosteroids, such as prednisone, and antibiotics, like cephalexin (cephalexin) or amoxicillin-clavulanate (amoxicillin-clavulanate)?

Systemic Corticosteroids for Eczema and Cellulitis

Do Not Use Systemic Corticosteroids for Concurrent Eczema and Cellulitis

Systemic corticosteroids should generally be avoided in patients with severe eczema and concurrent cellulitis due to unfavorable risk-benefit ratios and potential to worsen infection outcomes. 1 The priority is treating the cellulitis with appropriate antibiotics while managing eczema with topical therapies.

Treatment Algorithm for Eczema with Cellulitis

Step 1: Treat the Cellulitis First

Beta-lactam monotherapy is the standard of care for typical uncomplicated cellulitis, successful in 96% of patients. 2

• First-line oral antibiotics: Cephalexin 500 mg four times daily, dicloxacillin 250-500 mg every 6 hours, or amoxicillin-clavulanate 875/125 mg twice daily for 5 days if clinical improvement occurs 2
• Treatment duration: Exactly 5 days if improvement is demonstrated; extend only if symptoms have not improved within this timeframe 2
• MRSA coverage is NOT needed for typical nonpurulent cellulitis unless specific risk factors are present (penetrating trauma, purulent drainage, injection drug use, or known MRSA colonization) 2

Step 2: Manage the Eczema Concurrently with Topical Therapy

Topical corticosteroids remain first-line therapy for eczema when nonpharmacologic interventions have failed. 1

• Use potent or moderate-potency topical corticosteroids for moderate-to-severe eczema, applied once or twice daily 1, 3
• Moisturizers should be applied after bathing to maintain skin barrier function 1
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are effective steroid-sparing agents that can be used as maintenance therapy 1

Step 3: Consider Adjunctive Measures

• Elevate the affected extremity to promote drainage and hasten improvement of cellulitis 2
• Treat predisposing conditions including tinea pedis, venous insufficiency, and chronic edema to reduce recurrence risk 2
• Topical antiseptic preparations (bleach baths 0.005% sodium hypochlorite twice weekly) can be used in conjunction with topical anti-inflammatory therapy in infection-prone eczema patients 1

Why Systemic Corticosteroids Should Be Avoided

Evidence Against Systemic Steroids in Eczema

Systemic corticosteroids have a limited but definite role only for occasional patients with severe atopic eczema, and the decision should never be taken lightly. 1

• Short courses can lead to atopic flares after discontinuation 1
• Generally should be avoided given the risk/benefit ratio unless in cases with acute severe exacerbations and as bridge therapy to other systemic treatments 1
• Prednisolone is NOT recommended to induce stable remission of eczema—in a randomized trial, stable remission was achieved in only 1 of 21 patients (4.8%) receiving prednisolone compared with 6 of 17 patients (35.3%) treated with ciclosporin (P = 0.031) 4

Infection Risk with Systemic Steroids

Systemic corticosteroids could theoretically be considered in non-diabetic adults with cellulitis, though evidence is limited (weak recommendation, moderate evidence). 2 However, this applies only to cellulitis WITHOUT concurrent eczema. The immunosuppressive effects of systemic steroids may:

• Impair the immune response to bacterial infection
• Mask signs of worsening infection
• Increase risk of treatment failure or progression to deeper infection

When Hospitalization Is Required

Hospitalize if any of the following are present: 2

• Systemic inflammatory response syndrome (SIRS): fever, hypotension, altered mental status
• Severe immunocompromise or neutropenia
• Rapid progression or concern for necrotizing infection
• Failure to respond to outpatient oral antibiotics within 48 hours

For hospitalized patients with severe cellulitis and systemic toxicity, use vancomycin 15-20 mg/kg IV every 8-12 hours PLUS piperacillin-tazobactam 3.375-4.5 g IV every 6 hours for 7-10 days. 2

Common Pitfalls to Avoid

• Do not reflexively add MRSA coverage for typical nonpurulent cellulitis without specific risk factors—this represents overtreatment 2
• Do not use systemic corticosteroids as maintenance treatment for eczema until all other avenues have been explored 1
• Do not extend antibiotic treatment beyond 5 days based on residual erythema alone if clinical improvement has occurred 2
• Do not use doxycycline or trimethoprim-sulfamethoxazole as monotherapy for cellulitis, as their activity against beta-hemolytic streptococci is unreliable 2

Alternative Systemic Therapies for Severe Eczema (After Infection Resolves)

If systemic therapy for eczema is ultimately needed after the cellulitis has resolved:

• Cyclosporine 2.7-4.0 mg/kg daily is significantly more efficacious than prednisolone for severe adult eczema 4
• Other immunosuppressants (azathioprine, methotrexate, mycophenolate mofetil) should be considered before systemic corticosteroids 1
• Phototherapy (narrow-band UVB) is recommended for recalcitrant eczema after failure of first-line topical treatments 1