Treatments for skin infections

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Impetiginization

Signs of skin infection are sometimes difficult to differentiate from those of an AD flare-up. Local bacteriological samples are of little use during an AD flare because they do not change the therapeutic management, unless there is a risk of a resistant bacterial strain being present.

For the management of bacterial skin infections in AD (impetiginized lesions), we propose following the HAS (2019) recommendations, which recommend:

Bacteriological Sampling

Bacteriological sampling only for extensive impetiginized lesions (> 6 lesions or surface area ≥ 2% or rapid extension of lesions).

Cleaning with Soap and Water

• No use of topical antiseptics, regardless of the form, for the treatment of either atopic dermatitis in flare-up or for the treatment of impetiginization.

Oral Antibiotic Therapy

• Use of systemic antibiotics in a short course only for patients with extensive impetiginized lesions. Oral antibiotic therapy for 7 days, to be reassessed based on the results of the bacteriological sample. No topical antibiotic therapy.
• In adults:
  oral pristinamycin: 1 g x 3 /day or oral cephalexin: 2 to 4 g/day.
• In children:
  amoxicillin/clavulanic acid 80 mg/kg/day or cephalexin 50 mg/kg/day in 2 to 3 doses per day (HAS 2024 update)
• Exclusion from community settings for 3 days starting from the 1st day of treatment is advised for extensive forms.

Topical Antibiotic Therapy

• Use of topical antibiotics (mupirocin) in a short course in case of localized impetiginization.
• Topical antibiotic therapy with mupirocin 2 to 3 times per day for 5 days.

Continue topical anti-inflammatories in case of impetiginization, subject to appropriate antibiotic treatment (local and/or systemic).

HSV Infection

Infections by herpes simplex viruses (HSV), varicella-zoster virus (VZV), poxviruses, and coxsackieviruses are more frequent and more severe in patients with AD.

• Treat clinical suspicions of eczema herpeticum with systemic anti-herpetic treatment (orally or intravenously depending on severity) without waiting for HSV PCR results.
• Suspend topical anti-inflammatories in case of herpes viral infection for at least 48 hours after starting anti-herpetic treatment.

Molluscum Contagiosum

Molluscum contagiosum (linked to poxviruses) is common in patients with severe AD. Topical anti-inflammatory treatment may be continued.

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