Atopic eczema (atopic dermatitis or childhood eczema) is a big problem worldwide. The skin of people with atopic eczema often contains high numbers of a bacterium called Staphylococcus aureus (S. aureus).
Sometimes S. aureus results in an obvious secondary infection. Even when the eczema does not look infected S. aureus may still play a part in promoting skin inflammation. As a result, lots of eczema treatments have been developed to reduce S. aureus, including antibiotics taken by mouth, washing with antibacterial soaps or antibiotics combined with other eczema treatments. We undertook a systematic review on this topic as it is not clear which treatments offer any clinical benefit and because there is some concern that their widespread use may promote bacterial resistance.
Our review included 21 randomised controlled trials involving 1018 participants covering a range of anti-staphylococcal treatments: oral antibiotics (3 trials), antibacterial soaps (1 trial), topical steroids combined with antibacterials (10 trials), antibacterial bath additives (2 trials), topical antiseptic/antibiotics creams (4 trials) and silver impregnated textiles (1 trial). Generally, the quality of the reported studies was poor, and many were too small to identify important differences even if they existed. None of the trials showed any clear benefit in terms of short-term eczema control for any of the interventions tested, although several interventions were associated with decreased numbers of S. aureus on the skin. There was no clear evidence that widely used topical steroid/antibiotic combinations were any better than the topical steroids used alone. Adverse effects like irritation were especially poorly reported and only one study reported on the emergence of resistant bacterial strains in the group treated with oral antibiotics. Only one small inconclusive study evaluated people with clinically infected eczema.
Care should be taken in interpreting the above studies as failure to show benefit in a series of small, poorly reported studies does not mean that the anti-staphylococcal interventions could not be helpful in eczema. It is clinical common sense to treat overtly infected eczema with oral antibiotics, and that practice should continue until good evidence suggests otherwise. However, given that none of the other studies showed clear clinical benefit for anti-staphylococcal interventions in non-infected eczema, their continued use should be questioned in such situations. More studies should be done to look at the long-term possible benefits and harms of such interventions in preventing flares of atopic eczema.