What is the best treatment approach for a patient with eczema (atopic dermatitis) who develops folliculitis while using topical corticosteroids (CS)?

Management of Folliculitis in Eczema Patients Using Topical Corticosteroids

Immediate Action: Continue Topical Corticosteroids with Concurrent Antibiotic Therapy

When folliculitis develops in a patient with eczema who is using topical corticosteroids, do not discontinue the corticosteroids—instead, add appropriate systemic antibiotics while continuing the topical corticosteroid treatment. 1

This approach directly contradicts common clinical instinct but is supported by guideline evidence showing that topical corticosteroids remain the primary treatment even when infection is present, provided appropriate systemic antibiotics are given concurrently. 1

Identifying Secondary Bacterial Infection

Watch for these specific clinical signs that indicate folliculitis or secondary bacterial infection has developed:

• Increased crusting, weeping, or pustules on previously controlled eczematous skin 1
• Painful skin that was not previously tender 2
• Impetiginisation—honey-colored crusting caused by staphylococci or streptococci 3

Staphylococcus aureus is the most frequently detected infectious agent in secondary skin infections complicating eczema. 3

Antibiotic Selection and Administration

First-Line Systemic Antibiotic

• Flucloxacillin is the first-line oral antibiotic for treating Staphylococcus aureus folliculitis in eczema patients 1
• Take bacterial swabs before starting treatment to guide therapy if the patient fails to respond 3
• Continue treatment for one week 2

Evidence Against Topical Antibiotics

• Do not use topical antibiotics (such as fusidic acid) as they provide no clinically meaningful benefit over systemic antibiotics 2
• A 2017 randomized controlled trial in 113 children with clinically infected eczema found that neither oral flucloxacillin nor topical fusidic acid produced significant improvement in POEM scores compared to topical steroid and emollient alone 2

Modifying Topical Corticosteroid Strategy

Avoid Occlusive Products That Promote Folliculitis

• Stop using greasy creams for basic skin care as they facilitate folliculitis development through their occlusive properties 3
• Switch to lighter, non-occlusive emollient formulations (oil-in-water creams rather than heavy ointments) 3

Reassess Corticosteroid Potency

• Use topical corticosteroids under dermatologist supervision when infection complicates treatment, as they may cause perioral dermatitis and skin atrophy if used inadequately 3
• Consider whether the current potency is appropriate—potent or very potent corticosteroids should be used with caution for limited periods only 1
• Implement "steroid holidays" (short breaks from corticosteroids) when possible to minimize side effects 1, 4

Adjunctive Skin Care Modifications

Hygiene Measures to Prevent Further Infection

• Use gentle, pH-neutral (pH 5) bath and shower formulations with tepid water 3
• Pat skin dry after bathing rather than rubbing, using only clean and smooth towels 3
• Wear fine cotton clothes instead of synthetic materials that trap moisture and heat 3
• Avoid manipulation of the skin, including picking at pustules, as this increases infection risk 3

Continue Liberal Emollient Use

• Apply hypoallergenic moisturizing creams and emollients at least once daily to maintain skin barrier function 3
• Apply emollients after bathing to provide a surface lipid film that retards water loss 1
• Use soap-free cleansers rather than traditional soaps that remove natural skin lipids 1

When to Escalate Care

Indications for Urgent Referral

• Abscesses developing from folliculitis may require incision and drainage to prevent sepsis 3
• Grouped vesicles, punched-out erosions, or sudden deterioration with fever suggest eczema herpeticum—a medical emergency requiring immediate initiation of oral or intravenous acyclovir 1
• Failure to respond to moderate potency topical corticosteroids after 4 weeks warrants specialist referral 1, 4

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—this is the most critical error, as corticosteroids remain the primary treatment when appropriate systemic antibiotics are given 1
• Do not assume all infected-appearing eczema requires antibiotics—a 2017 trial showed rapid resolution with topical steroid and emollient alone in children with mild clinically infected eczema in ambulatory care 2
• Do not use topical corticosteroids continuously without breaks—implement steroid holidays to reduce the risk of skin atrophy and other complications 1, 4
• Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where folliculitis may be more likely to develop 1

Evidence Quality Considerations

The recommendation to continue topical corticosteroids during infection comes from high-quality guideline evidence (British Medical Journal guidelines) 1, while the evidence against routine antibiotic use in mild clinically infected eczema comes from a well-designed 2017 pragmatic randomized controlled trial 2. The guidance on avoiding occlusive products comes from expert consensus in the Annals of Oncology (though originally for EGFR-inhibitor reactions, the principle applies to folliculitis risk in eczema) 3.