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    Secondary infections in AD

    Symptoms and treatment protocols dermatologists should note


    Secondary infections vexing

    Often at medical meetings, "people like to talk about fascinating, juicy infectious diseases" most dermatologists never see, says Sheila Fallon Friedlander, M.D., professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

    However, she says, challenges that dermatologists face almost daily include secondary infections in atopic dermatitis (AD). In such cases, Dr. Friedlander says, it can be difficult to distinguish whether a patient is simply flaring, or suffering secondary infection.

    To resolve this conundrum, "We look for t he classic signs of infection – honey-colored crust and oozing. But often, a patient won't have classic findings. In such situations, utilizing appropriate dry skin care and topical corticosteroids may be enough to clear the patient, even if S. aureus is cultured from the site. If that doesn't work, empiric antibiotic therapy may be the next best step."

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    Research in this regard is "very interesting," she says. A large meta-analysis1 and several experts have stated that there is insufficient evidence to show a benefit of oral antibiotics in managing infected or uninfected eczema. However, says Dr. Friedlander, "This doesn't mean that antibiotics are ineffective. Many studies that have been performed are small and/or poorly designed."

    Accordingly, says Dr. Friedlander, "When we treat patients, we try to use our head. We know that it's important, when in doubt and before instituting therapy, to obtain cultures because of the high incidence of MRSA nationwide, and to help guide appropriate therapy. It's equally important to use oral antibiotics only when you believe they are appropriate."

    While awaiting culture results, she says, "If your community has a very high incidence of MRSA, as in Texas, use either clindamycin or Bactrim (sulfamethoxazole, trimethoprim; Roche). However, if you're in San Diego, where MRSA incidence is lower, particularly in patients with AD, we often start with a cephalosporin." Some physicians use clindamycin empirically, she says. But if a patient has no history of recurrent infections, and particularly no evidence of MRSA in any family contacts, "We'll start out empirically with cephalosporins."

    In one case Dr. Friedlander presented, a boy was treated with sulfamethoxazole-trimethoprim for possible MRSA, but the next day, his mother reported that his skin looked worse. Cultures taken from his lesional skin grew Group A Streptococcus. In one review of children with AD who underwent skin cultures, investigators found that 16 percent had Group A strep, and 14 percent had evidence of both staph and strep.2

    "A couple things are important here. First, the kids who have strep are more likely to be febrile, to have facial and perioral involvement and to be hospitalized, versus those with S. aureus alone." Second, Dr. Friedlander says, sulfamethoxazole-trimethoprim is ineffective against Group A strep.

    "That's why we generally don't use Bactrim as first-line therapy in children who look well, unless I'm certain or highly suspicious that it's MRSA." Conversely, she says that clindamycin and cephalosporins cover both strep and most staphylococcal infections. "Some MRSA strains won't be covered by clindamycin, but many will."

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    John Jesitus
    John Jesitus is a medical writer based in Westminster, CO.

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