Infection and Eczema
Margaret Cox, Chief Executive
National Eczema Society, United Kingdom
Broken skin provides an environment where micro-organisms can flourish. As a result, skin infections are not uncommon. Infections may be bacterial, fungal or viral.
Atopic eczema is most often infected by a bacterium called Staphylococcus aureus, which makes the eczema worse and slower to heal. Staph. aureus is found on the skin in less than 10% of healthy individuals.
By contrast, almost everyone who has atopic eczema will have Staph. aureus on their skin somewhere, even thought their skin may not show signs of infection. It is not clear whether the bacteria migrate from the active eczema to areas of skin without eczema or whether people with atopic eczema are simply more susceptible to Staph. aureus colonization than those without eczema.
Colonization is not normally a problem unless the skin is broken. Infection occurs only when the bacteria penetrates the skin’s barrier.
It is likely that people with atopic eczema have an impaired ability to deal with infection. In addition, as we know all too well from practical experience, eczema itches and the natural responses to itch is to scratch. This in turn causes the skin to crack and split and become red and inflamed, warm and moist – a perfect home for bacteria.
This is made worse by the itch-scratch-itch cycle and the vicious cycle that follows. It is also possible that the dry skin of atopic eczema is deficient in certain fatty acids, which may encourage the growth of bacteria.
The major virus that causes problems in people with eczema is the herpes simplex or cold sore virus. Many people who do not have eczema catch herpes simplex in childhood. It is usually very mild, causing a few mouth or gum ulcers that may not even be noticed.
Our bodies become immune after a first infection by herpes simplex – you tend not to catch it from anyone a second time. However, your own initial virus can become active again causing small, itchy blisters that quickly form a cold sore. This is how herpes simplex usually affects people who do not have eczema.
Herpes simplex is highly contagious and can appear as genital inflammation or conjunctivitis as well as cold sores. For people with eczema, the herpes simplex virus can be much more serious, probably because they have a lowered resistance to viruses. People with eczema should avoid skin-to-skin contact with anyone who has herpes simplex as this virus can infect eczema, giving rise to a condition called eczema herpeticum, which can cause serious illness.
Many children get molluscum contagiosum, but it may be slightly more common in atopic eczema sufferers. Molluscum contagiosum appears as small, smooth, red or flesh-colored bumps, each with a tiny dimple in the center. They often develop on eczema-prone areas such as skin folds behind the knees.
Candida or ‘thrush’ is a yeast or ‘fungal’ infection that may develop on skin with eczema, but can also appear on the skin of people without eczema. Candida likes warm, moist folds of skin such as the groin, under the arms and breasts or around the diaper area in babies.
Pityrosporum ovale is also a fungal infection, from the yeast pityrosporum, and can be found on the skin of people with seborrheic eczema. It likes to live where a lot of sebum (the body’s natural grease) is produced – for example, scalp, chest, ear folds and groin. Pityrosporum ovale may well be responsible for seborrheic eczema developing in many people.
What does infected eczema look like?
Infected atopic eczema looks red and angry, and is usually ‘weepy’ with a yellowish crust. Yellow pus-filled spots may also be present and small red spots around the body hairs (folliculitis). The skin feels hot, itchy and sore, which leads to more scratching. Scratching damages the outer layers of the skin and creates cracks allowing more bacteria to grow.
Occasionally the glands may swell and there may be an enlargement of lymph nodes in the neck, groin and armpits. Lymph nodes filter out bacteria and stop them from entering the bloodstream. Swollen lymph nodes can be tender to the touch. Infection should always be suspected if the eczema suddenly worsens or does not respond to emollient or topical steroid treatment.
Candida appears red, itchy and sore and there may also be tiny yellow pustules.
Eczema herpeticum produces small blisters, containing clear fluid or yellow pus, which break open and ulcerate the skin. Mild attacks are fairly common but in more serious cases, the virus spreads quickly on first infection. A high temperature and a general feeling of being unwell usually accompany it.
This form of eczema herpeticum is very dangerous and it is essential to contact a doctor immediately and to ask him or her if the symptoms could be eczema herpeticum.
Dermatologists, dermatology nurses and general practitioners with a special interest in dermatology may be able to tell if eczema is infected just by looking at it. Patients who have already experienced infection are also likely to recognize the signs and symptoms.
However, it is not always clear if eczema is infected, which can make diagnosis difficult. Your doctor may take a swab from the skin to be sent to the microbiology laboratory. This is a quick, painless procedure and can help to confirm what is causing the infection and can also show what antibiotics should be effective as treatment. Skin swabs frequently show the presence of Staph. aureus on the skin, but may also reveal additional bacteria called streptococci.
Treating Infected Eczema
Treatment depends upon the type of infection. Staph. aureus can be treated in several ways. For mild infections emollients and topical steroids, together with a bath oil containing an antiseptic may be sufficient. Sometimes a combination cream or ointment may be prescribed.
Antiviral drugs such as acyclovir are used to treat eczema herpeticum orally, by injection or in the form of a cream or ointment. If the eczema herpeticum is severe, a few days in the hospital may be needed to get the infection under control.
Candida is usually treated with an antifungal cream that can be prescribed by your doctor or dermatology nurse or bought over the counter from a pharmacist.
Using a medicated shampoo or an anti-yeast shampoo can treat Pityrosporum ovale on the scalp but will depend on the severity of the eczema. These shampoos are available from pharmacies. Several antifungal creams, with or without a mild steroid, are available to treat seborrheic eczema on other parts of the body.
There is no specific medicine to clear molluscum contagiosm. It is up to the body’s own immune system to get rid of the infection and unfortunately this can take months.
Infection and Your Other Treatments
Eczema patients who are using the topical immunomodulators Protopic and Elidel should not continue to use them if their eczema becomes infected. Speak to your doctor if you are using these products and suspect that your eczema may be infected.
Never use wet wrap bandages with infected eczema, as the moist, warm environment created by wet wraps is a perfect breeding ground for bacteria.
If your eczema is infected and you normally use emollient ointments, it may be worth asking your doctor to consider prescribing in addition an emollient cream to use some or all of the time while the infection persists. This is because in some people the ointment – which is occlusive – can also ‘trap in’ the infection.
Whatever emollients you are using, remember that it is easy to spread infection – both on your own skin and your child’s skin – and also to pass it from one person to another.
Pump dispensers reduce the risk, as does good hand hygiene before and after putting on emollients. If you do not have a pump dispenser, use a clean spoon to take the emollient out of the pot, rather than using your fingers.
Prevention of Infection in Eczema
Restoring the skin’s barrier to infection, be reducing dryness and cracking will help to reduce the entry points for bacteria. Intensive emollient therapy, with moisturizing creams and ointments, soap substitutes and emollient bath oils are essential. Daily baths and showers can help to prevent infection.
If someone in the family has a cold sore, it is important to refrain from sharing towels and face cloths. Ensure that you change bed linen regularly and wash it in a hot wash.
Even if you take preventative measures it is not always possible to stop eczema becoming infected. However, by treating with the most appropriate medication, the infection can be cleared and the eczema can be kept under control.
This article is graciously shared from Exchange, the member magazine of the National Eczema Society, London, England. Special thanks to Margaret Cox, Chief Executive. The recommendations contained in this article are those of the contributor. NEA provides health information from a variety of sources; this information is not intended as medical advice.