What is the best management approach for a patient presenting with weeping eczema, potentially complicated by bacterial infection?

Management of Weeping Eczema

Immediate First-Line Treatment Strategy

Continue topical corticosteroids as the primary treatment for weeping eczema even when bacterial infection is suspected, while simultaneously initiating oral flucloxacillin for confirmed or highly suspected bacterial superinfection. 1

The British Medical Journal guidelines are explicit: do not delay or withhold topical corticosteroids when infection is present—they remain the cornerstone of treatment when appropriate systemic antibiotics are given concurrently. 1

Recognizing Bacterial Superinfection

Watch for these specific clinical signs that indicate bacterial infection requiring antibiotic therapy: 1

• Increased crusting - honey-colored crusts are particularly suggestive 1, 2
• Weeping or oozing lesions - serous or purulent discharge 1, 2
• Pustules - discrete pus-filled lesions 1, 2
• Painful skin - increased tenderness beyond typical eczema discomfort 3

Critical caveat: These signs overlap significantly with non-infected eczema flares, making clinical diagnosis challenging. 4 Staphylococcus aureus colonizes 82.5-97% of eczematous skin, so positive skin swabs alone are unreliable for diagnosing true infection. 5, 4, 2

Antibiotic Selection and Administration

Oral flucloxacillin is the first-line antibiotic for Staphylococcus aureus, the causative organism in 97% of infected eczema cases. 1, 2

• Prescribe oral flucloxacillin for one week when bacterial infection is clinically suspected 1, 3
• Beta-hemolytic streptococci co-infection occurs in 62% of cases but flucloxacillin provides adequate coverage 2
• Avoid topical antibiotics - a 2017 randomized controlled trial demonstrated no clinically meaningful benefit from either oral or topical antibiotics added to standard therapy in ambulatory care settings 3

Important resistance patterns: 5

• Penicillin is NOT recommended - both MSSA and MRSA show complete resistance 5
• For multidrug-resistant infections, linezolid and vancomycin demonstrate high sensitivity including against MRSA 5
• MRSA shows complete resistance to penicillin, erythromycin, and cefuroxime, with 82% resistance to clindamycin 5

Topical Corticosteroid Application During Infection

Apply topical corticosteroids twice daily maximum to weeping areas, using appropriate potency based on location: 1

• Facial involvement: Use only low-potency preparations (1% hydrocortisone) due to thin skin and high atrophy risk 6
• Body/extremities: Moderate-potency corticosteroids are appropriate for initial control 1
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) 1

Implement "steroid holidays" - brief treatment breaks once acute weeping resolves - to minimize pituitary-adrenal suppression and local side effects. 1, 6

Essential Concurrent Emollient Therapy

Liberal emollient use is mandatory even during acute weeping phases: 1, 6

• Apply emollients immediately after bathing to damp skin to create a surface lipid film preventing water loss 1, 6
• Use soap-free cleansers or dispersible creams as soap substitutes - regular soaps strip natural lipids and worsen barrier dysfunction 1, 6
• Continue emollients regularly even when eczema appears controlled 1

Avoid greasy or occlusive products during active weeping as they can inhibit wound exudate absorption and promote superinfection. 7

Ruling Out Eczema Herpeticum - A Medical Emergency

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum and treat as a medical emergency. 1

• Initiate oral acyclovir immediately early in the disease course 1
• Administer intravenous acyclovir in ill, febrile patients 1
• Refer emergently to dermatology or admit to hospital 1, 6

When Standard Treatment Fails

Consider these scenarios requiring escalation: 1, 6

• Failure to respond to moderate-potency topical corticosteroids plus antibiotics after 4 weeks 1, 6
• Recurrent infections within 3 months - occurred in 32% of pediatric patients in one prospective study 2
• Need for systemic therapy or phototherapy 1
• 15% of bacterial infection episodes in children required hospital admission 2

Common Pitfalls to Avoid

• Do not withhold topical corticosteroids due to infection concerns - this is the most critical error, as steroids remain primary treatment with concurrent antibiotics 1, 6
• Do not rely on skin swab results alone - high colonization rates make positive cultures unreliable for diagnosing true infection 4
• Do not use topical antibiotics routinely - evidence shows no benefit over standard therapy in ambulatory settings 3
• Avoid continuous corticosteroid use without breaks - implement steroid holidays when acute phase resolves 1, 6
• Do not undertreat due to steroid phobia - explain that appropriate short-term use is safer than chronic undertreated inflammation 1, 6

Alternative Considerations for Refractory Cases

For patients where topical corticosteroids are unsuitable or ineffective: 7

• Topical tacrolimus may be considered, though it should not be used on clinically infected skin until infection resolves 8
• Before commencing pimecrolimus or tacrolimus, bacterial infections at treatment sites must be resolved 8
• These agents may independently increase risk of secondary infections including eczema herpeticum 8