How effective are interventions to reduce Staphylococcus aureus in eczema?

Key messages
Eczema is commonly colonized by Staphylococcus aureus so some advocate antibiotics or dilute bleach baths.

This Cochrane review evaluated trials of anti-staph treatments in people with infected or uninfected eczema.

From 41 trials (1753 participants), there was little evidence that these interventions impact eczema symptoms.

2.7 Authors’ conclusions
We found insufficient evidence on the effects of anti-staphylococcal treatments for treating people with infected or uninfected eczema. Low-quality evidence, due to risk of bias, imprecise effect estimates and heterogeneity, made pooling of results difficult. Topical steroid/ antibiotic combinations may be associated with possible small improvements in good or excellent signs/symptoms compared with topical steroid alone. High-quality trials evaluating efficacy, QOL and antibiotic resistance are required.

Eczema is associated with a significant health and socio-economic burden, and there is an acknowledged unmet need to improve overall patient management.6 This review updated evidence on the safety and effectiveness of anti-staphylococcal interventions in eczema management. Overall, these findings from 41 trials and 1753 children and adults with eczema found little evidence to support anti-staphylococcal measures for managing eczema. The key interventions assessed were topical antibiotics combined with topical steroids, oral antibiotics and dilute bleach baths. While one outcome measure showed a possible positive effect from topical antibiotics when added to topical steroid treatment, this finding was uncertain and other outcomes did not support an important clinical effect.

Updated NICE guidance on managing secondary infection of eczema was published in March 2021, and incorporated evidence from this updated Cochrane review.7 NICE recommend that in people who are not systemically unwell, clinicians should not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema. Use of antibiotics in non-severe infections can result in worsening of eczema, the risk of antimicrobial resistance is high with topical antibiotics, and therefore extended doses of the same antibiotics should be avoided to prevent resistance. The pattern of antimicrobial resistance varies internationally, with low fusidic acid resistance in South America, but high rates in the UK where combination products with topical steroid and fusidic acid have been commonly used.8 The use of topical agents such as antiseptics and bleach baths is not recommended by NICE due to insufficient evidence, which was identified in this updated Cochrane review.

Overall, there is insufficient evidence to recommend use of anti-staphylococcal interventions in the treatment of clinically infected or non-infected eczema, although in patients with systemic signs of infection such as cellulitis, systemic antibiotics have an important role in helping clear infection.