Topical Mupirocin for Folliculitis in Eczema Patients on Topical Corticosteroids
Do not use topical mupirocin as monotherapy for folliculitis in eczema patients—instead, continue topical corticosteroids and add oral flucloxacillin as first-line treatment. 1
Primary Treatment Strategy
Continue topical corticosteroids during the infection while adding systemic antibiotics concurrently. 1 This approach directly contradicts the common misconception that topical steroids should be stopped when infection develops. The British Medical Journal guidelines explicitly recommend maintaining topical corticosteroid therapy alongside appropriate systemic antibiotics in eczema patients who develop folliculitis. 1
Why Oral Antibiotics Over Topical Mupirocin
Oral flucloxacillin is the first-line antibiotic for Staphylococcus aureus folliculitis in eczema patients, as it is the most frequently detected infectious agent in secondary skin infections complicating eczema. 1, 2
Long-term application of topical antibiotics is not recommended because of increased risk of bacterial resistance and skin sensitization. 2
Recent high-quality evidence demonstrates no clinically meaningful benefit from topical antibiotics in infected eczema. A 2017 pragmatic randomized controlled trial in 113 children with clinically infected eczema found that neither topical fusidic acid nor oral flucloxacillin added benefit beyond topical corticosteroids and emollients alone, with rapid resolution occurring in all groups. 3 However, this study focused on mild infections in ambulatory care, and the guideline consensus still supports systemic antibiotics for clinically evident bacterial infection. 2, 1
When Topical Mupirocin May Have a Role
Intranasal mupirocin may be recommended to reduce Staphylococcus aureus colonization and disease severity in moderate to severe atopic dermatitis with clinical signs of secondary bacterial infection. 2 This targets nasal carriage rather than treating active folliculitis directly.
Evidence for Mupirocin Efficacy (Historical Context)
While older studies from 1989-2000 demonstrated mupirocin's effectiveness against staphylococci and streptococci in primary and secondary skin infections 4, 5, 6, current guidelines have moved away from topical antibiotics due to resistance concerns and lack of added benefit in the context of eczema management. 2, 3
Modifying Your Topical Regimen
Avoid occlusive products that promote folliculitis development. 1, 2 Switch from greasy creams to lighter, non-occlusive emollient formulations while maintaining appropriate topical corticosteroid therapy. 1
Supportive Skin Care Modifications
Use gentle, pH-neutral bath and shower formulations with tepid water to prevent further infection. 1
Pat skin dry after bathing rather than rubbing, using only clean and smooth towels to reduce infection risk. 1
Keep nails short and avoid manipulation of the skin to prevent secondary infection. 2
Clinical Assessment Before Treatment
Take bacterial swabs before starting treatment to guide therapy if the patient fails to respond to initial management. 1, 2 Look for clinical signs of impetiginisation—honey-colored crusting caused by staphylococci or streptococci—which indicates secondary bacterial infection requiring systemic antibiotics. 1
When to Escalate Care
Urgent referral is needed for abscesses developing from folliculitis, which may require incision and drainage to prevent sepsis. 1, 2
Immediate initiation of oral or intravenous acyclovir is required for eczema herpeticum, characterized by grouped vesicles, punched-out erosions, or sudden deterioration with fever—this is a medical emergency that can progress rapidly to systemic infection. 1, 2
Common Pitfalls to Avoid
Do not delay or withhold topical corticosteroids when infection is present—this worsens the underlying eczema and perpetuates the cycle of inflammation and infection. 1 Topical corticosteroids themselves reduce Staphylococcus aureus colonization by decreasing inflammatory reaction and improving skin barrier function. 2
Avoid using topical corticosteroids continuously without breaks, as this increases the risk of skin atrophy and other complications when used inadequately or without dermatologist supervision. 1, 2