Skin infections and eczema

The skin is the most important protection we have against infection as it provides a barrier that prevents the billions of bacteria found on our skin from entering the body. 

Staphylococcus aureus (Staph. aureus) is the bacterium that is most commonly responsible for secondary infection of eczema. It is often associated with hair follicle infections (folliculitis), boils and abscesses. ‘Impetiginized eczema’ is another label or name given to eczema infected with Staph. aureus. When the bacteria penetrate the epidermis, an immune reaction can be triggered, which aggravates the eczema and brings about a flare. 

Initially, eczema infected by Staph. aureus will appear itchy and red or darker than your usual skin colour, depending on skin tone. If you look closely in natural light, you might see a tangerine glisten to the skin – a little bit like orange body shimmer dust. As the infection progresses, weeping and crusting with a yellow/golden tinge will be evident. 

Bacterial skin infections are treated with antibiotics, either topically (applied to the skin) using a cream, or orally (by mouth) in the form of tablets or a liquid suspension. Whether the doctor gives you a topical or oral treatment depends on the size of the affected area/s and the number of places where the infection occurs. It is important when treating the infection with a cream that you apply it consistently and for the prescribed duration (in the same way you would take a course of oral antibiotics). Topical antibiotics should not be used for longer than 14 days due to the risk of bacterial resistance. 

Skin infections can sometimes be caused by a resistant strain of Staphylococcus aureus, such as methicillin-resistant Staph. aureus (MRSA), often referred to as a ‘superbug’ in the media. If you are not responding to antibiotics, a skin swab should be taken to confirm the strain of bacteria and the antibiotics to which it is sensitive. MRSA bacteria are usually spread through skin-to-skin contact with someone who has an MRSA infection or has the bacteria living on their skin. MRSA can also be spread through contact with everyday objects such as towels, sheets, taps, surfaces and door handles. 

There are some steps you can take to reduce your risk of picking this up: 

• Careful hand-washing before applying your emollients and treatments. 

• When visiting a clinic or hospital, use the hand gels available beside doorways and report any unclean toilet or bathroom facilities to the staff. 

Fortunately, MRSA bacteria are not resistant to all antibiotics, so MRSA infections can be treated. Skin infections due to MRSA are usually treated with antibiotics in tablet form, or sometimes injections if the infection is widespread.

As with bacteria, certain fungi live naturally on everyone’s skin. There are two main fungal infections that affect people with eczema. One is caused by Candida, a yeast that thrives in warm, moist areas of the body, such as under the arm, groin, and neck area in children. The other type originates from moulds called dermatophytes that cause an infection known as tinea or ringworm (this describes the shape of the skin lesions and has nothing to do with actual worms!). 

Candida infections can be treated with a cream containing clotrimazole. This can be purchased from a pharmacy. 

Tinea infections are named according to the part of the body where they are found: tinea corporis on the body, tinea capitis on the scalp, tinea pedis on the feet. Tinea infections are often difficult to distinguish from discoid eczema. Usually, the doctor or nurse will prescribe a fungal treatment (miconazole cream) – also available over the counter from a pharmacy – to see if the skin responds and the lesions clear. For tinea infections of the scalp or nails, an oral antifungal agent will be necessary. Your GP will need to prescribe this. A skin scraping can be taken for mycology (fungal) analysis when there is difficulty resolving the lesions, and there is doubt about the diagnosis. 

Antifungal creams do not entail the same resistance concerns as antibiotic creams, so you can apply them as and when they are needed. For best results, consistency with application is required until the lesions are clear, applying three times a day or as directed by your doctor. 

Eczema herpeticum

The herpes simplex virus usually just causes cold sores, but in people with eczema it can spread through the skin and develop quickly into a serious condition called eczema herpeticum. The symptoms of this viral infection include: 

• areas of painful eczema that quickly get worse 

• groups of fluid-filled blisters that break open and leave small, shallow, open sores on the skin 

• a high temperature and generally feeling unwell (in some cases). 

Obtaining treatment quickly is important with this infection – it should not be left until morning! You should see a doctor immediately if you think you have eczema herpeticum, and if you cannot be seen by your GP, call NHS 111 or attend the nearest A&E department. 

The virus is spread through direct contact, both skin to skin and contact with surfaces (the virus can live for a few hours on a hard surface). To prevent infection spreading, let the surgery or hospital staff know on arrival that you think you have eczema herpeticum, so you can wait in a private area until the doctor assesses you. If you have eczema herpeticum, you will be treated with an antiviral drug called aciclovir; often, patients are admitted to the hospital for a few days in order to receive the therapy intravenously. 

Childhood infections, which can be worse when you have an underlying diagnosis of eczema, include the following: 

Chickenpox 

The presentation of chickenpox can be variable, from just a few pustules to extensive pustules covering the entire skin’s surface and inside the mouth and ears. The infection is spread through blood, saliva and cough droplets. 

Children with atopic eczema have a slightly higher likelihood of developing a complication of the infection. Parents will need to closely monitor them and their well-being by checking their temperature, looking for infected lesions and seeking medical advice if concerned. 

If you have taken oral steroids within three months of contracting chickenpox, you may have a lowered ability to fight the infection, and you will require closer monitoring by your GP. Oral antivirals or hospital admission may be needed to prevent complications. Topical steroids and topical calcineurin inhibitors (pimecrolimus and tacrolimus) are less of an issue. See your GP for advice on continuing these treatments while you have new chickenpox lesions. Calamine lotion can be drying on the skin and is not usually helpful in children with eczema. 

Molluscum contagiosum 

This is a common childhood infection. The papules last between a few months and up to two years. They are highly contagious, and rubbing or scratching them helps them to spread on the skin. Treatment is not usually given as these viral lesions do eventually go away by themselves. 

Scabies 

Scabies are tiny mites that burrow and lay eggs in the outer layers of skin. Scabies infestations are very itchy and produce a rash. They are more common in children with eczema and are difficult to diagnose as the presentation is similar to that of eczema; also, the scabies may be hidden by the eczema. Scabies like warm places, such as skin folds, webs of the fingers, the feet and around the buttocks or breast creases. They can also hide under watch straps, bracelets or rings. The incubation period is up to 8 weeks, and dry, scratched skin helps the infestation to spread. See your GP or pharmacist if you think you have scabies – it is not a serious condition, but it does need treating. Permethrin cream and malathion lotion are medications that contain insecticides that kill the scabies mite. They are available to purchase over the counter from a pharmacist.