What are the best strategies to prevent recurrent infections in a patient with a history of eczema?

Preventing Recurrent Infections in Eczema

Implement a three-tiered prevention strategy: optimize skin barrier function with daily emollients and soap-free cleansers, maintain strict wound hygiene with covered drainage and hand washing, and consider decolonization with intranasal mupirocin plus dilute bleach baths if infections recur despite these measures. 1

First-Line Prevention: Restore and Maintain Skin Barrier

The foundation of infection prevention is aggressive emollient therapy and elimination of irritants. 1, 2

• Apply emollients liberally at least twice daily, ideally immediately after bathing when skin is most hydrated to lock in moisture 2, 3
• Replace all soaps and detergents with dispersible cream cleansers as soap substitutes, since these products strip natural lipids from already compromised skin 1, 2
• Bathe with lukewarm water for 5-10 minutes, adding bath oils according to patient preference for both cleansing and hydration 1, 2
• Keep fingernails short to minimize skin damage from scratching, which creates portals for bacterial entry 1, 2, 3
• Use cotton clothing next to skin and avoid wool or synthetic fabrics that may irritate and worsen barrier disruption 1, 2

Second-Line Prevention: Hygiene and Wound Care Measures

Strict personal and environmental hygiene prevents bacterial transmission and colonization. 1

Personal Hygiene Protocol:

• Keep all draining wounds covered with clean, dry bandages at all times 1
• Wash hands with soap and water or alcohol-based hand sanitizer regularly, particularly after touching infected skin or items that contacted draining wounds 1
• Avoid reusing or sharing personal items (disposable razors, linens, towels) that have contacted infected skin 1

Environmental Hygiene Protocol:

• Focus cleaning efforts on high-touch surfaces that contact bare skin daily: counters, door knobs, bathtubs, toilet seats 1
• Use commercially available cleaners or detergents appropriate for each surface according to label instructions 1

Household Contact Management:

• Evaluate all household contacts for evidence of Staphylococcus aureus infection 1
• Treat symptomatic contacts immediately; consider nasal and topical body decolonization following treatment of active infection 1

Third-Line Prevention: Decolonization Strategies

Decolonization should be considered only after optimizing wound care and hygiene measures, if recurrent infections persist or ongoing household transmission occurs. 1

When to Implement Decolonization:

• Patient develops recurrent skin and soft tissue infections despite optimized wound care and hygiene 1
• Ongoing transmission occurs among household members or close contacts despite optimized measures 1

Decolonization Regimens (choose one):

Option 1 (Nasal only):

• Mupirocin 2% ointment intranasally twice daily for 5-10 days 1

Option 2 (Combined nasal and body - preferred for recurrent infections):

• Mupirocin 2% ointment intranasally twice daily for 5-10 days PLUS 1
• Chlorhexidine body wash for 5-14 days OR 1
• Dilute bleach baths: 1 teaspoon per gallon of water (or ¼ cup per ¼ tub/13 gallons) for 15 minutes twice weekly for 3 months 1

Important Decolonization Considerations:

• Screening cultures prior to decolonization are not routinely recommended if at least one prior infection was documented as MRSA 1
• Decolonization strategies must be offered in conjunction with ongoing reinforcement of hygiene measures, not as standalone therapy 1
• Consider decolonizing asymptomatic household contacts if household transmission is suspected 1

Maintain Adequate Eczema Control

Uncontrolled eczema with active inflammation increases infection risk through barrier disruption and bacterial colonization. 1, 3

• Use topical corticosteroids as the mainstay of treatment, applying the least potent preparation required to control eczema 1, 3
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently 1, 3
• Implement short "steroid holidays" when possible to minimize adverse effects while maintaining control 1, 3
• Consider topical calcineurin inhibitors (tacrolimus) for sensitive areas like the face, particularly when prolonged treatment is needed 3

Recognize and Treat Infections Early

Early recognition and treatment of breakthrough infections prevents progression and reduces bacterial burden. 1

Bacterial Infection Signs:

• Increased crusting, weeping, or pustules suggest Staphylococcus aureus infection 1
• Obtain bacterial cultures if patients do not respond to initial treatment or have severe infection 1
• Use systemic antibiotics only for frank bacterial infections with purulent exudate, not for colonization alone 1

Viral Infection Signs:

• Grouped vesicles, punched-out erosions, or sudden deterioration with fever suggest eczema herpeticum - a dermatologic emergency 1, 3
• Initiate systemic acyclovir immediately if eczema herpeticum is suspected 1, 3

Pediatric-Specific Considerations

For children with secondarily infected eczema lesions, mupirocin 2% topical ointment can be used for minor infections. 1

• Avoid tetracyclines in children under 8 years of age 1
• For hospitalized children with complicated skin infections, vancomycin is recommended, or clindamycin if clindamycin resistance rate is low (e.g., <10%) 1

Common Pitfalls to Avoid

• Do not use systemic antibiotics empirically for uninfected or colonized eczematous skin - this increases bacterial resistance without improving disease outcomes, and colony counts return to previous levels within days to weeks of discontinuation 1
• Do not delay hygiene and wound care education - these measures are as important as pharmacologic interventions and must be reinforced at every visit 1
• Do not implement decolonization as first-line therapy - optimize barrier function and hygiene first, as decolonization without these measures will fail 1
• Do not withhold topical corticosteroids when infection is present - they remain essential for controlling inflammation when appropriate systemic antimicrobials are given 1, 3