NEWPORT BEACH, CALIF.– In children with atopic dermatitis, serious superinfections are more likely to be caused by group A beta-hemolytic Streptococcus than methicillin-resistant Staphylococcus aureus, according to Dr. Victoria Barrio of the University of California, San Diego.
Unless there are classic MRSA signs, “I wouldn’t start off with Bactrim [sulfamethoxazole and trimethoprim] assuming that they have MRSA; Bactrim doesn’t work for strep. You are going to be in trouble if they actually have strep,” she said at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.
Dr. Victoria Barrio
Instead, Dr. Barrio is more likely to start empirically with cephalexin (Keflex) three times daily, which also covers staph in most communities. “It’s usually well tolerated, and it does pretty well,” she said, but adding that she adjusts treatment as needed depending on culture results.
This protocol is supported in part by findings from a study by colleagues of Dr. Barrio, which showed that children with atopic dermatitis carry more S. aureus on their skin than do children without eczema, so they are less likely to be infected with community-acquired MRSA, probably because non-MRSA strains outcompete it. In the study, the MRSA the investigators found responded to clindamycin (Pediatr. Dermatol. 2011;28:6-11).
Dr. Barrio cited another study suggesting that group A strep skin infections are a more serious problem than staph is in children with eczema; the children are more likely to be febrile, have systemic involvement, and need hospitalization than those with staph superinfections (Pediatr. Dermatol. 2011;28:230-4).
“These patients are often a lot sicker. You have to be aware that strep is out there, and it can be a problem for kids with eczema,” said Dr. Barrio.
In general, for bacterial superinfections, “bleach baths are a fantastic way to try to keep kids who are always getting infected under control,” she said. It really does keep that overload of bacteria down.”
Current data support her opinion. Following a course of antibiotics, another study showed that twice-weekly baths, followed by intranasal mupirocin ointment had “significantly greater mean reductions from baseline in Eczema Area and Severity Index scores,” compared with placebo (Pediatrics 2009;123:e808-14).
For older children who don’t want to take baths, a bleach soap (CLn Bodywash) is now available, Dr. Barrio noted.
Viral eczema coxsackium skin infections, recently characterized in the literature, remain a problem for children. Presentations can vary and include widespread blisters, erosions, purpura, and petechiae around the mouth or on the arms, legs, and torso. The infection can mimic bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease,and it is a common cause of onychomadesis as well, Dr. Barrio noted (Pediatrics 2013;132:e149-57).
“We saw a lot of it a few years ago. I am still seeing it around. You don’t really think about it as being hand, foot, and mouth” disease, she said.
Dr. Barrio added that eczema is hard on children emotionally as well as physically. They may lose sleep, have a tough time in school, and might blame the illness on themselves, and these and other problems can lead to depression, anxiety, and a big hit to self-esteem, she said.
Clinicians at the University of Nottingham (U.K.) have created a free web resource that might help, which features stories for children. The clinicians have posted several tales, like “The Princess and the Itch,” that make eczema the villain and the child the hero, which helps to externalize the disease. The child’s name can be entered into a template to personalize the story (Pediatr. Dermatol. 2013;30:765-7). Dr. Barrio had no relevant disclosures. SDEF and this news organization are owned by Frontline Medical Communications.