What is the appropriate management of weeping eczema?

Management of Wet (Weeping) Eczema

Weeping eczema indicates secondary bacterial infection and requires concurrent treatment with systemic antibiotics (flucloxacillin as first-line) while continuing topical corticosteroids—do not delay or withhold steroids when infection is present. 1, 2, 3

Immediate Assessment and Recognition

When you encounter weeping or crusting eczema, this signals secondary bacterial infection, most commonly with Staphylococcus aureus. 1, 2 Key clinical features to identify include:

• Crusting or weeping lesions suggest bacterial superinfection 1
• Grouped, punched-out erosions or vesiculation indicate possible herpes simplex infection (eczema herpeticum)—this is a medical emergency 1, 2
• Take bacteriological swabs if the patient fails to respond to initial treatment 1

Core Treatment Algorithm

Step 1: Initiate Systemic Antibiotics

• Flucloxacillin is the first-line oral antibiotic for treating S. aureus, the most common pathogen in weeping eczema 1, 2, 3
• Use phenoxymethylpenicillin if β-hemolytic streptococci are isolated 1
• Erythromycin is appropriate for penicillin allergy or flucloxacillin resistance 1

Step 2: Continue Topical Corticosteroids

This is a critical point where many clinicians make errors: Do not stop topical corticosteroids when infection is present. 2, 3

• Topical corticosteroids remain the mainstay of treatment even during active infection, provided appropriate systemic antibiotics are given concurrently 1, 2, 3
• Apply topical corticosteroids no more than twice daily to affected areas 2
• Use the least potent preparation that controls symptoms 2, 4
• For mild eczema, 1% hydrocortisone is adequate and does not cause systemic side effects unless used extravagantly 1, 4

Step 3: Aggressive Emollient Therapy

• Liberal use of emollients is essential for both cleansing and providing a protective barrier 2, 4
• Apply emollients after bathing to provide a surface lipid film that retards evaporative water loss 1, 2, 4
• Use dispersible cream as a soap substitute—avoid regular soaps and detergents that strip natural skin lipids 1, 4
• Regular bathing is beneficial for cleansing and hydrating the skin 1, 2

Step 4: Adjunctive Measures

• Keep nails short to minimize trauma from scratching 1
• Avoid irritant clothing such as wool; cotton clothing is preferred 1
• Avoid extremes of temperature 1

Special Consideration: Eczema Herpeticum

If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency. 2, 3

• Initiate oral acyclovir early in the disease course 1, 2
• In ill, feverish patients, administer acyclovir intravenously 1, 2
• Send swabs for virological screening and electron microscopy 1

Common Pitfalls to Avoid

• Never delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given 2, 3
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 2, 4
• Address patient or parent fears about steroids directly, as steroid phobia leads to undertreatment in 72.5% of patients 4
• Very potent and potent corticosteroids should be used with caution for limited periods only 1, 2
• Avoid high-potency steroids on face, neck, and skin folds where atrophy risk is higher 4

When to Refer or Escalate

• Failure to respond to treatment after appropriate antibiotics and topical therapy 1
• Suspected eczema herpeticum (immediate referral required) 2, 3
• Need for systemic therapy or phototherapy 2, 4
• Failure to respond to moderate potency topical corticosteroids after 4 weeks 2, 4