In a patient with eczema who has lesions where a bacterial or fungal superinfection cannot be ruled out, how should the condition be safely managed?

Management of Eczema with Suspected Bacterial or Fungal Superinfection

Continue topical corticosteroids while initiating appropriate systemic antimicrobial therapy—do not delay or withhold anti-inflammatory treatment when infection is present. 1, 2

Immediate Clinical Assessment

Distinguish bacterial from viral superinfection:

• Bacterial infection (most commonly Staphylococcus aureus) presents with increased crusting, weeping, purulent exudate, and pustules 1, 2
• Eczema herpeticum (herpes simplex virus) presents with grouped vesicles, punched-out erosions, or sudden deterioration with fever—this is a medical emergency requiring immediate antiviral therapy 1, 2
• Obtain bacteriological swabs from affected areas before starting antibiotics, though treatment should not be delayed if clinical infection is evident 2, 3

For fungal concerns:

• When bacterial or fungal superinfection is suspected but cannot be distinguished clinically, obtain cultures and initiate systemic treatment based on the most likely pathogen while awaiting results 1
• Pityrosporum species (yeast) may be relevant particularly in head and neck eczema 4

Systemic Antimicrobial Therapy

First-line bacterial treatment:

• Flucloxacillin is the recommended first-line oral antibiotic for S. aureus infection in eczema 2
• For penicillin allergy or suspected flucloxacillin resistance, use erythromycin as an alternative 2, 3
• If β-hemolytic streptococci are isolated, prescribe phenoxymethylpenicillin 2
• Treatment duration is typically 7-10 days 3

For eczema herpeticum:

• Start oral acyclovir immediately when suspected 1, 2
• In febrile or systemically ill patients, administer intravenous acyclovir 1, 2
• Early initiation directly correlates with shorter hospital stays and improved outcomes 1

Concurrent Topical Corticosteroid Management

Critical principle: Do not stop topical steroids during infection

• Maintain topical corticosteroids during active bacterial infection when appropriate systemic antibiotics are given concurrently 1, 2
• Apply topical corticosteroids no more than twice daily to affected areas, using the least potent preparation that controls symptoms 2
• For mild disease, 1% hydrocortisone is sufficient and produces no systemic effects when used appropriately 2
• If using combination antibiotic/corticosteroid creams, appropriate antimicrobial therapy should be instituted per FDA labeling 5

Essential Adjunctive Skin Barrier Care

Emollient therapy remains foundational:

• Apply emollients liberally and regularly, ideally immediately after bathing, to create a surface lipid film that reduces evaporative water loss 2, 6
• Use soap-free cleansers and dispersible cream as soap substitutes; avoid regular soaps that strip natural lipids 2, 3
• Regular bathing supports skin cleansing and hydration 2

Reduce mechanical trauma:

• Keep nails short to limit skin trauma from scratching 2
• Choose cotton clothing and avoid irritant fabrics such as wool 2

Monitoring and Reassessment

Follow-up timeline:

• Reassess within 48-72 hours to evaluate response to antibiotics and topical therapy 3
• If no improvement after initial treatment, obtain bacterial cultures with antibiotic susceptibility profiling for recurrent or non-responsive infections 1, 6
• Refer to dermatology if no improvement after 4 weeks of appropriate treatment 2, 3

Critical Pitfalls to Avoid

Common errors that worsen outcomes:

• Never delay topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given 1, 2
• Do not use systemic antibiotics empirically for uninfected or colonized eczematous skin without clinical signs of infection, as this increases bacterial resistance without improving disease outcomes 1, 6
• Avoid very potent corticosteroids in thin-skinned areas (face, neck, flexures, genitals) where risk of atrophy is higher 2
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible 2

Special Considerations for Fungal Superinfection

When fungal infection is confirmed:

• Systemic antifungal treatment should be based on culture results 1
• Both antimicrobial and antifungal treatment have been shown helpful in cases of atopic eczema with documented superinfection 4
• Continue standard eczema management with emollients and appropriate-potency topical corticosteroids alongside antifungal therapy 7, 8