Infected Eczema
Infected eczema means Atopic Dermatitis skin that has picked up a secondary infection. The usual cause is the bacterium Staphylococcus aureus, sometimes together with streptococci. Less often, and more dangerously, the cause is Herpes Simplex Virus, which produces Eczema Herpeticum. Toddlers are at risk because eczema skin is cracked and leaky (Skin Barrier Dysfunction), the Itch-Scratch Cycle keeps breaking it open, and S. aureus already lives on about 70% of eczema lesions (Totté, BJD 2016). Infection is the main acute complication of childhood eczema and a common reason a flare suddenly “won’t settle” (NICE NG190).
Staphylococcus aureus [causes] Infected Eczema Herpes Simplex Virus [causes] Eczema Herpeticum Eczema Herpeticum [part-of] Infected Eczema Skin Barrier Dysfunction [precedes] Infected Eczema Itch-Scratch Cycle [worsens] Infected Eczema
Recognising it. NICE NG190 lists the signs of bacterial infection: weeping, pustules, crusts, no response to treatment, rapidly worsening eczema, fever and malaise. Golden-yellow crusting is the classic “impetiginised” look (Impetigo). NICE also warns that eczema is often colonised without being infected, and that not every weepy, crusted flare is bacterial or will respond to antibiotics. Viral infection (eczema herpeticum) looks different. It causes painful clusters of identical small blisters and 1–3 mm punched-out erosions, often on the face, usually with fever (NICE QS44; DermNet). Any “infected eczema” that is not improving on antibiotics should be re-examined for herpes (NG190).
Infected Eczema [relates] Impetigo NICE NG190 [defines] Infected Eczema
Treatment in brief. For bacterial infection, NG190 advises that children who are not systemically unwell usually do not need antibiotics. Their usual Emollient Therapy and Topical Corticosteroids carry on, and they are reassessed if things worsen. If an antibiotic is needed:
- Fusidic Acid 2% cream for 5–7 days for small, localised patches.
- Oral Flucloxacillin for 5–7 days for widespread or severe infection, or a child who is unwell.
- Clarithromycin if the child is penicillin-allergic.
Old emollient tubs and creams should be replaced after an infection (NICE CG57). The evidence for treating the bacteria is thin. The Cochrane review by George et al. (2019; 41 RCTs) found only a possible small gain from steroid/antibiotic combination creams. It found no clear benefit from oral antibiotics, Bleach Baths, antiseptic soaps or bath additives. For herpes infection, the treatment is immediate systemic Aciclovir plus same-day specialist review (NICE QS44). Each day of delay lengthened hospital stay in a 1,331-child cohort (Aronson, Pediatrics 2011).
Flucloxacillin [treats] Infected Eczema Fusidic Acid [treats] Infected Eczema Aciclovir [treats] Eczema Herpeticum Topical Corticosteroids [treats] Infected Eczema Cochrane [relates] Infected Eczema
When to see a doctor. This guide is built from NHS, NICE NG190 and NICE QS44/CG57:
| Situation | Action |
|---|---|
| Eczema is weepy, crusty, has pus spots, or is painful, swollen or warm, but the child is well | Urgent GP appointment, or NHS 111 (call 111 for under-5s) (NHS) |
| Eczema suddenly worsens or spreads, or child has a high temperature or seems generally unwell | Urgent same-day GP or 111. Possible bacterial infection or eczema herpeticum (NHS) |
| Painful clustered blisters or punched-out sores, especially with fever, lethargy or distress | Emergency, same day: needs aciclovir now and specialist or hospital care (NICE QS44; CKS) |
| Any blisters or sores near the eyes | Same-day eye assessment as well (NICE CG57 via QS44; DermNet) |
| Infection not improving after a course of antibiotics, or keeps coming back | Return to GP: swab, reconsider herpes, consider decolonisation or referral (NG190) |
| Spreading redness, severe pain out of proportion, floppy or drowsy child | Hospital / A&E: possible cellulitis, sepsis or necrotising fasciitis (NG190 1.1.15) |
Do not treat suspected infected eczema with home remedies
Weeping, crusting, blistering or fever in a toddler with eczema needs medical assessment, not a switch to “natural” creams, oils or honey. Herbal creams can hide undeclared steroids (Adulterated Herbal Creams). Essential oils and fragrance sting and sensitise broken skin (Essential Oils). Delaying aciclovir in eczema herpeticum measurably worsens outcomes (Aronson 2011).
NICE CG57 [regulates] Infected Eczema Infected Eczema [precedes] Eczema Herpeticum
Connections
- Atopic Dermatitis — infection is its main acute complication, source: NICE NG190
- Staphylococcus aureus — principal bacterial cause; colonises ~70% of lesions, source: Totté BJD 2016; NG190
- Eczema Herpeticum — viral form; emergency, source: NICE QS44; DermNet
- Herpes Simplex Virus — cause of eczema herpeticum, source: DermNet
- Impetigo — the impetiginised (golden-crusted) presentation, source: NHS
- Flucloxacillin — first-line oral antibiotic if needed, source: NICE NG190
- Fusidic Acid — first-line topical for localised infection, source: NICE NG190
- Aciclovir — immediate treatment for eczema herpeticum, source: NICE QS44
- Bleach Baths — no clear benefit in RCTs, source: Cochrane 2019
- Cochrane — George 2019: insufficient evidence for anti-staph interventions, source: Cochrane CD003871
- NICE NG190 — antibiotic stewardship guideline for infected eczema, source: NICE
- NICE CG57 — eczema herpeticum and infection advice for under-12s, source: NICE QS44
- Emollient Therapy — continue during infection; replace contaminated tubs, source: NG190; CG57
- Topical Corticosteroids — continue during bacterial infection, source: NG190
- Skin Barrier Dysfunction — leaky skin lets bacteria and virus in, source: NHS
- Itch-Scratch Cycle — scratching breaks skin and spreads infection, source: NHS
- Adulterated Herbal Creams — hazard when parents self-treat flares, source: MHRA (see note)
- Essential Oils — hazard on broken, infected skin, source: see note
- Differential Diagnosis of Toddler Eczema — complication rather than mimic, source: Siegfried & Hebert 2015