Eczema and Infection


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Eczema, also known as atopic dermatitis, is a chronic skin condition which affects 15–20% of the population in developed countries including the United States. It is characterized by an eczematous eruption, itching and skin sensitivity to irritants. It is the most common diagnosis for patients seen in pediatric dermatologists’ offices.1This article will discuss some of the infections associated with this diagnosis.SECONDARY BACTERIAL INFECTIONSWith damaged protective skin function and disturbance of quantity and quality of skin lipids, patients with eczema may develop secondary bacterial infections.2Staphylococcus aureus (SA) organisms are most often the etiologic agents. In fact, as many as 90% of patients with eczema are colonized with staphylococcal organisms. The progression from colonization to infection often is associated with a flare of the eczema. Increased severity of the eczema is associated with a higher level of colonization.3 More erythema may be noted when the infection begins; then, the affected areas become crusted or can have a serous drainage. With the recent increase in methicillin-resistant Staphylococcus aureus (MRSA), treatment of secondary infection of eczema with these organisms can be challenging. Patients with eczema and secondary bacterial skin infections should be treated with topical steroids or other anti-inflammatory medications and moisturizers to repair the skin barrier. The level of skin colonization with S. aureus is decreased with the use of these agents alone.4 Appropriate topical or systemic antibiotics based on specific or community-based sensitivities may be necessary in more severe cases.ECZEMA HERPETICUMBecause of the damaged protective skin function, cutaneous inoculation of herpes simplex virus (HSV) can occur. Eczema herpeticum (aka Herpes Simplex Virus–associated Kaposi varicelliform eruption) is a term which describes eczema which has been secondarily infected with the HSV (either HSV type 1 or type 2).5,6 The eczema may become more erythematous; then, vesicles develop which are arranged in a grouped pattern. Accompanying symptoms include fever, malaise, and lymphadenopathy.7 The diagnosis can be made by a Tzanck smear (looking for multinucleated giant cells), a fluorescent antibody smear, or culture of a vesicular lesion. The child may have recurrences in the same areas that were involved initially. Patients with eczema herpeticum should be treated with acyclovir (the oral antiviral approved for use in patients under 18 years of age). More severe involvement may require hospitalization and use of systemic antivirals. In addition, it is recommended that topical steroids and moisturizers be continued to repair the skin barrier.ECZEMA MOLLUSCATUMChildren with eczema have more infections with molluscum contagiosum and tend to have more widespread disease.5,8,9 The lesions are noted to be smooth papules, sometimes umbilicated, occurring on both involved and uninvolved skin. The lesions can spread by auto-inoculation to surrounding areas. Molluscum dermatitis accompanies 10% of molluscum lesions and the dermatitis can be difficult to distinguish clinically from eczema lesions. Molluscum contagiosum lesions can be left untreated and will in some cases resolve on their own. Alternatively, the lesions can be treated with cantharidin, liquid nitrogen, or curettage. The molluscum dermatitis is treated with topical steroids (the appropriate potency based on the location on the body).ECZEMA VACCINATUMSmallpox vaccine is made from live vaccinia virus. At the time smallpox vaccinations were being recommended, concern was raised for children who came in contact with the vaccinated adults.10 The patients who are most likely to develop eczema vaccinatum (aka Vaccinia-associated Kaposi varicelliform eruption) are <5 years of age and have a history of eczema.11,12 There is a mortality risk, even in individuals without active eczema.

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