Antibiotics unnecessary for mild clinically infected eczema in children
The use of oral or topical antibiotics has little effect on children with mild clinically infected eczema, according to findings from the UK-based CREAM* study.
“Children with clinically infected eczema flares in primary care recovered quickly with use of mild-to-moderate strength topical corticosteroids and did not benefit from the addition of either oral or topical antibiotics,” said the researchers. “... Providing (or stepping up the potency of) topical corticosteroids and emollients should be the main focus in the care of milder clinically infected eczema flares.”
Participants were 113 children (mean age 3.1 years, 54 percent female) who presented at ambulatory care with clinical, nonseverely infected eczema. They were randomized to the oral antibiotic group (flucloxacillin or erythromycin suspension, 2.5 mL 4 times a day for children ≤2 years or 5 mL 4 times a day for older children, and topical placebo, n=36), the topical antibiotic group (2% fusidic acid applied 3 times a day, and oral placebo, n=37), or control group (oral and topical placebos, n=40), with treatments administered for 7 days.
All participants were also supplied with topical corticosteroids (hydrocortisone 1% for the face and clobetasone butyrate 0.05% or equivalent for the body) and a nonantimicrobial emollient.
Children with significant comorbidities or severe infections, and those who recently used potent topical corticosteroids or antibiotics were excluded.
All groups experienced reductions in mean Patient Oriented Eczema Measure (POEM) scores at 2 weeks (from 13.4 to 6.2 in the control group, from 14.6 to 8.3 in the oral antibiotic group, and from 16.9 to 9.3 in the topical antibiotic group). At 3 months, mean POEM scores were 7.7, 7.8, and 7.9 in the control, oral antibiotic, and topical antibiotic groups, respectively. [Ann Fam Med 2017;15:124-130]
There was no difference in mean POEM score at 2 weeks between the oral antibiotic and topical antibiotic groups (intervention effect, 1.5, 95 percent confidence interval [CI], -1.4 to 4.4 and 1.5, 95 percent CI, -1.6 to 4.5, respectively) compared with the control group.
Staphylococcus aureus was present in 69.6 percent of participants at baseline, which reduced to 44 percent at 2 weeks and 36 percent at 3 months, with no significant difference between treatment groups.
The researchers acknowledged that the findings may not extend to all populations, including older children, other ethnicities, or those with more severe infection. Furthermore, the lack of a standard definition on what constitutes infected eczema suggests that not all participants may have had an infection.
“A greater understanding of different eczema infective flare phenotypes would help better define the boundary between those who clearly do not benefit from antibiotics and those who might,” they said.
Dr Lynn Chiam, dermatologist at Children&Adult Skin Hair Laser Clinic, Mount Elizabeth Novena Specialist Centre, Singapore, who was not affiliated with the study, agreed that antibiotics are not necessary for mildly infected eczema.
“My decision to start antibiotics is based on clinical grounds. If the infected area is large and the eczema flare is severe, I will start antibiotics. I will [also] commence oral antibiotics if I suspect cellulitis,” she said.
Children who suffer from recurrent flares of infected eczema will benefit from the use of antibiotics. Other factors that go into consideration include eczema and infection severity, extent or surface area affected, and the age of the child, she said, stressing on the importance of regular and long-term use of emollients, even on areas that are not affected by eczema.