Treatment of Staphylococcus aureus Colonization in Atopic Dermatitis Decreases Disease Severity

Abstract

Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Pediatrics. 2009;123(5). Available at: www.pediatrics.org/cgi/content/full/123/5/e808PURPOSE OF THE STUDY. To determine the rate of methicillin-resistant Staphylococcus aureus (MRSA) colonization in children with moderate-to-severe atopic dermatitis (AD) and to investigate the use of bleach baths and intranasal mupirocin treatment in management.STUDY POPULATION. Patients (N = 31) 6 months to 17 years of age with moderate-to-severe AD and signs of bacterial skin infection were recruited from a dermatology clinic in Children's Memorial Hospital (Chicago, IL).METHODS. This was a randomized, investigator-blinded, placebo-controlled study. All patients were initially treated with cephalexin for 14 days and were then assigned randomly to receive intranasal mupirocin ointment (versus petrolatum placebo) twice daily for 5 days per month and to use one half cup of bleach (versus placebo water) in 40 gallons of bathwater for soaking for 5 to 10 minutes twice weekly. Treatment was undertaken for 3 months. The primary outcome measure was the Eczema Area and Severity Index score.RESULTS. S aureus was cultured from 81% of the nares and 87% of lesional skin samples, and the prevalence of MRSA was 4% of nasal cultures and 7.4% of skin cultures. Treated subjects, compared with control subjects, showed significantly greater mean reductions from baseline in Eczema Area and Severity Index scores at the 1-month and 3-month visits (P = .004). The improvement was attributable to score changes for body areas that had been submerged in the dilute bleach baths (score change at 3 months: treated: −4.9; placebo: −0.9; P = .0005).CONCLUSIONS. The authors concluded that chronic use of dilute bleach baths with intermittent intranasal application of mupirocin ointment decreased the clinical severity of AD in patients with clinical signs of secondary bacterial infections and that these patients did not have increased susceptibility to MRSA.REVIEWER COMMENTS. Noting the significant role of S aureus in the etiology of AD (as reviewed above), the use of bleach baths has been recommended for many years; however, study of the approach has been lacking. Clinicians must recognize that the approach here was targeted to a specific population (moderate-to-severe AD with superinfection) and more than just bleach baths were used (initial cephalexin treatment and also mupirocin and emollient/antiinflammatory drug therapies). While we await additional studies on the efficacy and safety (including promotion of resistance) of the studied approach, the lesson here includes the utility of a multifaceted approach to AD management that addresses infection.