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EDITORIAL
Year : 2005  |  Volume : 71  |  Issue : 2  |  Page : 71-72

Should topical antibacterials be routinely combined with topical steroids in the treatment of atopic dermatitis?


Pediatric Dermatology Division, Institute of Child Health, Kolkata, India

Correspondence Address:
Sandipan Dhar
Flat No. 2A2, Block-2, 5, N.S.C Bose Road, Kolkata - 700 040
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0378-6323.13987

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How to cite this article:
Dhar S. Should topical antibacterials be routinely combined with topical steroids in the treatment of atopic dermatitis?. Indian J Dermatol Venereol Leprol 2005;71:71-2

How to cite this URL:
Dhar S. Should topical antibacterials be routinely combined with topical steroids in the treatment of atopic dermatitis?. Indian J Dermatol Venereol Leprol [serial online] 2005 [cited 2019 Oct 21];71:71-2. Available from: http://www.ijdvl.com/text.asp?2005/71/2/71/13987


Since Leyden et al showed in 1974 that 90% of patients with atopic dermatitis (AD) have their skin colonized with Staphylococcus aureus (SA),[1] the increased incidence of a carrier state of SA in patients with AD has been a subject of interest. Several studies in children[2],[3],[4] and adults[5],[6] with AD have demonstrated an increased carrier state of SA in both involved and uninvolved skin. AD is reported to be exacerbated when the density of SA is greater than 106 CFU/cm2 (CFU, colony forming unit).[6]



Although Staphylococcus aureus can be isolated from the anterior nares in approximately 30% of normal individuals and less commonly from the flexures, it is rarely a member of the normal resident flora in human skin.[7] Hence, while there may not always be any evidence of frank infection, the staphylococcal superantigens produced by SA may actually perpetuate the eczema and produce steroid insensitivity.[8] Topical and/or systemic antibiotics reduce the quantity of SA colonizing the skin and nasal mucosa, and thus improve the eczema.[4],[5],[6],[7] Topical mupirocin is highly effective against all strains of SA and is effective in clearing SA from the skin and nasal mucosa.[9],[10]



One can therefore presume that a combination of a moderately potent topical corticosteroid like fluticasone and an antibiotic like mupirocin should tackle atopic dermatitis more effectively than fluticasone alone. In this issue, Khobragade reports that two weeks of treatment with a combination of fluticasone and mupirocin led to a significant improvement in AD in 90% of patients in an open label uncontrolled study.[11] However, until randomized controlled trials establish the superiority of this combination to fluticasone alone over a longer period, this combination should be judiciously used by dermatologists.



In the majority of patients with AD, SA colonizes eczematous and normal looking skin without any overt signs of infection.[1],[2],[4],[5],[6] Whenever there is improvement in eczema due to treatment with a potent topical steroid, the SA count also goes down.[12],[13] Hence, it may be expected that addition of a topical antibacterial may bring about faster improvement in eczema. However, when there is evidence of frank infection, an oral rather than a topical antibiotic should be used. It is important to remember that mupirocin or a mupirocin-fluticasone combination should not be used over large areas of skin because this can lead to the emergence of resistance to this very useful topical antibiotic.[14] In patients with widely distributed eczematous lesions, a course of an oral anti-staphylococcal antibiotic is preferable to a topical steroid-antibiotic combination. Several studies, including one by our group, have found that such a course improves the eczema even in patients without evident infection.[4],[5],[6],[15] Once the lesions become localized, application of a topical steroid alone to the residual lesions should suffice. In my experience, a topical steroid-antibiotic combination is most appropriate for treating eczematous lesions close to the anterior nares, flexures, perianal areas, and finger or toe web spaces.



In another article in this issue, Sharma reports contact allergy to neomycin, gentamicin and chinoform in patients with AD.[16] The risk of sensitization is the main reason why most dermatologists do not prefer neomycin as a topical antibiotic in patients with AD.[17] In India neomycin-containing topical antibacterials are commonly prescribed for cuts, abrasions, minor burns, furuncles, etc. The incidence of cross-sensitivity between neomycin and gentamicin is as high as 40%.[18] Topical betamethasone in combination with gentamicin has been successfully used to treat AD for the past two decades.[19] However, it is quite possible that gentamicin might induce sensitization in many patients with AD and that patients who cease to respond to a topical steroid-gentamicin combination are actually developing sensitivity to gentamicin rather than tachyphylaxis to steroids (which is what we usually suspect). The sensitization potential of mupirocin does not appear to be a major issue presently. However, with increasing usage mupirocin allergy may become more common.[20],[21]



The combination of mupirocin and fluticasone is currently available only as an ointment. In India, where the climate is hot and humid for most of the year, a cream, which is non-greasy and more acceptable to patients, would be preferable to an ointment. A preparation combining mupirocin and hydrocortisone may also be useful.

 
  References Top

1.Leyden JJ, Marples RR, Kligman AM. Staphylococcus aureus in the lesions of atopic dermatitis. Br J Dermatol 1974;90:525-30.  Back to cited text no. 1  [PUBMED]    
2.Hoeger PH, Lenz W, Boutonnier A, Fournier JM. Staphylococcal skin colonization in children with atopic dermatitis; Prevalence, persistence and transmission of toxigenic and non-toxigenic strains. J Infect Dis 1992;165:1064-8.  Back to cited text no. 2  [PUBMED]    
3.Goodyear HM, Watson PJ, Egan SA, Price EH, Kenny PA, Harper JI. Skin microflora in of atopic dermatitis in first time hospital attenders. Clin Exp Dermatol 1993;18:300-4.  Back to cited text no. 3  [PUBMED]    
4.Dhar S, Kanwar AJ, Kaur S, Sharma P, Ganguly NK. Role of bacterial flora in the pathogenesis and management of atopic dermatitis. Indian J Med Res 1992;95:234-8.  Back to cited text no. 4  [PUBMED]    
5.White MI, Noble WC. Consequences of colonization and infection by Staphylococcus aureus in atopic dermatitis. Clin Exp Dermatol 1986;11:34-40.   Back to cited text no. 5  [PUBMED]    
6.Hauser C, Wuetrich B, Matter L, Wilhelm JA, Sonnabend W, Schopfer K. Staphylococcus aureus skin colonization in atopic dermatitis. Dermatologica 1985;170:35-9.  Back to cited text no. 6      
7.Bibel DJ, Greenberg JH, Cook JL. Staphylococcus aureus and the microbial ecology of atopic dermatitis. Can J Microbiol 1977;23:1062-8.  Back to cited text no. 7  [PUBMED]    
8.McFadden JP, Noble WC, Camp RD. Superantigenic exotoxin secreting potential of staphylococci isolated from eczematous skin. Br J Dermatol 1993;128:631-2.  Back to cited text no. 8  [PUBMED]    
9.Lever R, Hadley K, Downey D, Mackie R. Staphylococcal colonization in atopic dermatitis and the effect of topical mupirocin therapy. Br J Dermatol 1988;119:189-98.  Back to cited text no. 9  [PUBMED]    
10.Luber H, Amornsiripanitch S, Lucky AW. Mupirocin and the eradication of Staphylococcus aureus in atopic dermatitis. Arch Dermatol 1988;124:853-4.  Back to cited text no. 10  [PUBMED]    
11.Khobragade KJ. Efficacy and safety of combination ointment fluticasone propionate 0.005% plus mupirocin 2% for the treatment of atopic dermatitis with clinical suspicion of secondary bacterial infection: An open label uncontrolled study. Indian J Dermatol Venreol Leprol 2005;71:92-6.  Back to cited text no. 11      
12.Nilsson EJ, Henning CG, Magnusson J. Topical corticosteroids and Staphylococcus aureus in atopic dermatitis. J Am Acad Dermatol 1992;27:29-34.   Back to cited text no. 12  [PUBMED]    
13.Stadler JF, Fleury M, Sourisse M, Rostin M, Pheline F, Litoux P. Local steroid therapy and bacterial skin flora in atopic dermatitis. Br J Dermatol 1994;131:536-40.  Back to cited text no. 13      
14.Mupirocin-resistant Staphylococcus aureus. Lancet 1987;2:387-8.   Back to cited text no. 14  [PUBMED]    
15.David TJ, Cambridge GC. Bacterial infection and atopic eczema. Arch Dis Child 1986;61:20-3.  Back to cited text no. 15  [PUBMED]    
16.Sharma AD. Contact allergic dermatitis in patients with atopic dermatitis: A clinical study. Indian J Dermatol Venereol Leprol 2005;71:97-9.  Back to cited text no. 16      
17.Polano MK, De Vries HR. Analysis of results obtained in the treatment of atopic dermatitis with corticosteroid and neomycin containing ointments. Dermatologica 1960;120:191-9.  Back to cited text no. 17  [PUBMED]    
18.Rudzki E, Zakrazewski Z, Rebandel P, Grzywa Z, Hudymowicz W. Cross reaction between aminoglycoside antibiotics. Contact Dermatitis 1988;18:314-6.  Back to cited text no. 18      
19.Wachs GN, Maibach HI. Co-operative double-blind trial on an antibiotic/corticoid combination in impeginized atopic dermatitis. Br J Dermatol 1976;95:323-8.  Back to cited text no. 19  [PUBMED]    
20.Zappi EG, Brancaccio RR. Allergic contact dermatitis from mupirocin ointment. J Am Acad Dermatol 1997;36:266.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Jappe U, Schnuch A, Uter W. Frequency of sensitization to antimicrobials in patients with atopic eczema compared with nonatopic individuals: Analysis of multicentre surveillance data, 1995-1999. Br J Dermatol 2003;149:87-93.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  



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