Infected Eczema

Comments from Expert Advisory Group

  • Patients should be encouraged to use emollients regularly
  • Emollients help to reduce dryness, which can improve the barrier function of the skin, easing itch and pain while reducing exposure to bacteria and sensitising antigens
  • Signs and symptoms of secondary bacterial infection of eczema can include:
    • Weeping
    • Pain
    • Crusting of lesions (similar in appearance to impetigo)
    • Pustules
    • Rapidly worsening eczema
    • Fever
    • Malaise
  • Staphylococcus aureus is the most common bacteria implicated in infection
  • In patients who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary bacterial infection of eczema
  • Evidence suggests there is a limited benefit in using combination topical antibiotic/corticosteroid preparations compared with topical corticosteroids alone
  • Swabs are not indicated unless in cases of treatment failure or atypical bacterial cause suspected
  • Reserve topical antimicrobials for localised infections
  • To reduce the risk of antimicrobial resistance:
    • Topical antimicrobials and oral antimicrobials should not be used concomitantly
    • Topical antimicrobials should be used for a limited period (<2 weeks)
  • Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staphylococcus aureus and is associated with persistent recurrent pustules and carbuncles or cellulitis. Send swabs for culture in these clinical scenarios. On rare occasions it causes more severe invasive infections, even in otherwise fit people. Risk factors include: nursing homes, contact sports, sharing equipment, poor hygiene and eczema.

Infected Eczema                    

Image source: Dermnet







Eczema Herpeticum

  • Eczema herpeticum is a severe skin infection caused by the dissemination of the herpes simplex virus. It is characterised by:
    • Areas of rapidly worsening and painful eczema
    • Clustered blisters consistent with early-stage cold sores
    • Punched-out erosions usually 1mm to 3mm in diameter, which are uniform in appearance. These may coalesce into larger areas of erosions
    • Possible fever, distress or lethargy
  • It is a dermatological emergency, warranting same day referral to local dermatology department / hospital

Facial Eczema Herpeticum

Image Source: Dermnet






Eczema Herpeticum on the chest

Image Source: Dermnet







Infection Prophylaxis

Bleach Baths

  • Bleach baths are an option for infection prophylaxis
  • Limited evidence to support their use, however they are commonly used in practice
  • Should not be used during active infection
  • May reduce the bacterial load on the skin and contribute to reduced numbers of infections
  • To be used once or twice a week

Bleach Bath Recipe

Ingredients required
  • Milton Sterilising Fluid®
    • This is a form of bleach, containing 2% sodium hypochlorite
    • Other bleaches can be used but they should be free of perfumes, colours and consist of 2% sodium hypochlorite
How to use a bleach bath
  1. Fill bath with desired amount of warm water.
  2. Add Milton Sterilising Fluid® to the bath and completely mix it in. You should aim to use 2mls of Milton Sterilising Fluid® for every litre of bath water. This is roughly half a cup (150mls) to a full adult bath tub (containing water to a depth of 10cm).
  3. Soak in the bath water up to your neck for about 10 minutes. For smaller children, use a sponge or flannel to soak any dry and affected areas that are out of the water.
  4. At the end of the bath, rinse well with fresh warm water (this could be done in the shower).
  5. As soon as the bath is over, pat the skin dry. Do not rub as this may irritate the skin.
  6. Immediately apply any prescribed emollients and other treatments.
  • Never use undiluted bleach products directly on the skin
  • Avoid getting undiluted or diluted bleach into the eyes
  • Do not swallow bleach water
  • Avoid adding bleach to very hot water, as this may produce fumes
  • Bleach products may make the bath slippery
  • Bleach products will cause discolouration of clothing and towels, so avoid contact with items of clothing which may be affected and use white towels if possible


Infected Eczema Treatment
Drug Children's Dose Adult Dose Duration  Notes
1st choice option




See flucloxacillin dosing table for children



500mg every 6 hours



7 days



Avoid in penicillin allergy

To optimise absorption, take on an empty stomach (either 1 hour before food or 2 hours after).

2nd choice options    
Cefalexin See cefalexin dosing table for children  500mg every 12 hours 7 days Cephalosporins should not be used in severe penicillin allergy.




See clarithromycin dosing table for children


250mg every 12 hours
(can be increased if necessary in severe infection to 500mg every 12 hours)

7 days



Macrolides should be used with caution in pregnancy. Clarithromycin suitable only in 2nd and 3rd trimester in pregnancy.


1st choice option in pregnant, penicillin allergic patients    


  300mg every 6 hours 7 days Caution: risk of C. difficile.
Topical Treatment (Reserve for localised infections)
Fusidic Acid Topically to affected areas every 8 hours 5-7 days  

Patient Information

Safe Prescribing (visit the safe prescribing page)

    Reviewed November 2022

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