This study examined the skin microbiome (skin bacteria) of 75 Egyptian patients with atopic dermatitis (AD), compared to 20 health controls. It was found that the bacterial diversity of skin microbiome in patients with AD was less than those of the healthy subjects. Eczema children, adolescents and adults have bacteria, Streptococcus, Cutibacterium, and Corynebacterium, while Staphylococcus was noted as a potential biomarker candidate for AD. These bacteria also exacerbated eczema. Total immunoglobulin E (IgE – antibodies that reacts to an allergen, causing allergic reaction) levels were positively correlated with certain Staph bacteria.
What it means for Eczema Skincare
The skin microbiome of eczema children is different from normal skin, which has been covered in-depth in this Staph Bacteria on Eczema Skin series with past president of American Academy of Dermatology, Dr Clay Cockerell. Limiting staph bacteria colonization on eczema skin is one of the recommended therapeutics, with one of the most commonly heard of ways to reduce staph bacteria being the bleach bath. Reducing staph bacteria is also one of the skincare aspect which my daughter’s doctor (and also co-author for Living with Eczema: Mom Asks, Doc Answers) recommended us to work on.
You can talk the same to your doctor whether the use of anti-microbial cleanser, swimming (literally a ‘fun’ way to kill the harmful skin bacteria, while splashing and soaking in the pool!) or chlorhexidine gluoconate wipe (it is cheaper if you purchase a bottle at the pharmacy and pour on disposal cotton pad to wipe skin, rather than buy the ready-made wipes. The bottle can be stored in fridge) at eczema lesions area are appropriate. We tried all the above, and even now, regularly uses an anti-microbial cleanser. You can also explore some baby clothing made with silver or bamboo material with anti-microbial properties.
In this study, it was noted that Staphylococcus aureus colonization on AD skin had been directly correlated to eczema severity. It was thus important to study how skin bacteria affect skin inflammation.
It was also noted in this study that skin bacterial diversity is smaller than in healthy subjects. Through a panel of Canadian dermatologists, the consensus was that:
(1) In atopic patients, the skin microbiome of lesional atopic skin is different from nonlesional skin in adjacent areas.
(2) Worsening atopic dermatitis and smaller bacterial diversity are strongly associated.
(3) Application of emollients containing antioxidant and antibacterial components may increase microbiome diversity in atopic skin.
Have you found something that works? Share in the comments if you have found reducing staph bacteria to be helpful in managing your child’s eczema. I’m bringing back a new season of Someone has Eczema series, please let me know if you like to share your story to encourage all of us.
I’m privileged to interview the lead researcher for the study, Dr Donald J Davidson MBChB PhD. Dr Davidson is the MRC Senior Research Fellow and University of Edinburgh Senior Lecturer. The Davidson Group within the MRC Centre for Inflammation Research focuses on understanding the physiological importance of cationic host defence peptides (CHDP) to host defences against bacterial and viral infections. Dr Davidson is a medical graduate of the University of Edinburgh who chose to pursue a scientific research career. He completed a PhD at the MRC Human Genetics Unit, studying the pathogenesis of cystic fibrosis lung disease, then was awarded a Wellcome Trust Travelling Research Fellowship to undertake post-doctoral training in innate immunity research at the University of British Columbia, Vancouver. You can read more of his research interests here.
MarcieMom: Thank you Dr Davidson for taking the time to help with the questions. The questions will be based on the study, but more focused on its practical implications.
Staphylococcus aureus is a resilient bacteria found on the skin that can survive in dry condition and on dry skin with little oxygen. It tends to involve areas that are warm and moist especially such as skin near mucous membranes such as the nose, mouth, genitals and anal area. It is found in less than 30% of healthy adults and generally does not cause an infection in those with healthy skin. However, as pointed out in the study, 75% to 100% of atopic dermatitis patients have staph bacteria on their lesional skin and 30% to 100% of atopic dermatitis patients have staph bacteria on their non-lesional skin (Breuer et al., 2002; Gong et al., 2006; Park et al., 2013). The problem with staph bacteria is that it secretes toxins and proteases that can worsen atopic dermatitis.
MarcieMom: From your study, protease V8 was of interest which showed it led to skin barrier dysfunction. Can you explain what you learnt about staphylococcus aureus’ interaction with atopic dermatitis skin/ normal skin and how does it damage skin integrity?
Dr Davidson:In our study we did not use the whole live bacteria, but concentrated instead on its harmful proteases. Using skin cells grown in the laboratory and collecting the substances made by the bacteria Staphylococcus aureus, we were able to show that the bacterial protease V8 was the most powerful product when it came to breaking down and damaging the skin barrier. Together with studies from other research groups, this suggested that one of the main ways these bacteria can damage skin is by producing V8, and that finding ways to block this damage may help to maintain and/or restore the skin integrity in atopic dermatitis.
Natural Skin Defence
In your study, it was mentioned that human beta defensin 2 (hBD2) is a substance on our skin that have antimicrobial properties and able to protect against skin integrity damage caused by staph bacteria protease V8. It was further noted that the level of hBD2 on atopic dermatitis skin was significantly lower than normal skin, therefore atopic dermatitis skin may be more prone to infection and unable to defend itself against staph bacteria.
MarcieMom: I hope I have understood hBD2’s role correctly; can you explain more about what you have found out about hBD2, for instance, how important is its role in maintaining skin integrity, fighting infection and the effects of protease V8?
Dr Davidson: Our bodies can make quite a wide range of substances we call antimicrobial host defence peptides (HDP). The skin is one site that produces these. These HDP have a lot of different roles in protecting us from infection and disease. hBD2 is an HDP from the defensin family. hBD2 was already known to be capable of killing bacteria in the laboratory. It is less clear if it definitely does this in normal functioning on our skin. However, it has been suggested by other researchers that the failure of atopic dermatitis skin to make as much hBD2 as one would expect (for the amount of skin inflammation or damage), could be one reason that atopic dermatitis skin lesions are prone to infection. What our new MRC-funded research discovered was that hBD2 can also stop V8 from damaging laboratory-grown skin. This worked both when we instructed the skin to make extra hBD2 (using genetic modification) and when we added hBD2 in the style of a treatment. Just how important this is in a living human remains to be seen, but it has obvious potential and shows that hBD2 can protect the skin barrier as well as kill bacteria.
MarcieMom: The interesting part of your study was its demonstration that application of hBD2 was found to be protective, and therefore a possible future eczema therapeutic. How does the application of hBD2 work? What are its protective effects?
Dr Davidson:At this point we don’t know how hBD2 protects this skin barrier integrity and we are currently applying for more funding so that we can start to work this out. It may act directly on the V8 to block the damaging effects of this bacterial protease, but we’ve found that it can also help to speed up repair where damage has occurred. So hBD2 may work in more than one way.
Is this something you foresee that can be easily added into a moisturizer or would it be more likely to be a non-steroidal topical prescription?
Dr Davidson: At this stage we are still in the discovery science phase of the research, so it is too early to predict how, and even whether, it will turn out to be a useful treatment. However, in the best case scenario for the outcome of our research, I would envisage adding hBD2 (or drugs made to mimic some of its functions) into prescription moisturizer-type creams or ointments.
How would the application of hBD2 be compared with the existing eczema measures such as bleach bath to kill staph bacteria?
Dr Davidson: I’m afraid it is too early to be able to make comparisons of that kind, until we have a better understanding of exactly how hBD2 functions to protect the skin barrier.
MarcieMom: Thank you Dr Davidson once again for your time and will certainly look forward to further breakthroughs and more studies done in this area.
1.Wang B, McHugh BJ, Qureshi A, Campopiano DJ, Clarke DJ, Fitzgerald JR, Dorin JR, Weller R, Davidson DJ, IL-1beta-induced protection of keratinocytes against Staphylococcus aureus-secreted proteases is mediated by human beta defensin 2, The Journal of Investigative Dermatology (2016), doi: 10.1016/j.jid.2016.08.025.
2. Breuer K, S HA, Kapp A, Werfel T (2002) Staphylococcus aureus: colonizing features and influence of an antibacterial treatment in adults with atopic dermatitis. Br JDermatol 147:55-61.
3. Gong JQ, Lin L, Lin T, Hao F, Zeng FQ, Bi ZG, et al. (2006) Skin colonization by Staphylococcus aureus in patients with eczema and atopic dermatitis and relevant combined topical therapy: a double-blind multicentre randomized controlled trial. Br J Dermatol 155:680-7.
4. Park HY, Kim CR, Huh IS, Jung MY, Seo EY, Park JH, et al. (2013) Staphylococcus aureus Colonization in Acute and Chronic Skin Lesions of Patients with Atopic Dermatitis. Ann Dermatol 25:410-6.
This is a continuation of last week’s interview with Dr Steve Xu MD MSc where we discussed contact dermatitis, the differences between irritant and contact dermatitis, the top 10 pediatric contact allergens in personal hygiene products and practical consideration of when to suspect contact dermatitis in a child.
Practically it can be difficult to find a skincare product with less than 10 ingredients! Pharmaceutical companies seem to add more ingredients to their formulation in order to ‘upgrade’ their product to one that can restore your skin’s lipids, ceramides, reduce itch and bacterial infection.
MarcieMom: Is there a trend towards more ingredients in the formulation of skincare products? And is it a real risk or can consumers assume that product companies would have tested their increasingly complex formulation that it would not lead to contact dermatitis?
Dr Steve Xu: Again, labels such as ‘hypo-allergenic’ or ‘sensitive skin’ really don’t mean anything. The Food and Drug Administration do not regulate this definition. Consumers have to be aware of this.
I wouldn’t say there’s a trend towards more ingredients in skincare products. Skincare products aren’t produced for hypo-allergenicity. These products are successful because they smell nice (fragrances), feel good on the skin, and stay fresh (preservatives). I think for individuals with patch-test proven allergic contact dermatitis, it’s really important to follow the safe list. But, if you haven’t been patch tested yet and have very sensitive skin, then looking for products with as few ingredients as possible AND do not have common skin allergens is a reasonable consideration.
Staph Bacteria and Antiseptic Moisturizer
MarcieMom: Staph bacteria has been covered in my blog, and we know that eczema skin that has staph bacteria colonization will not recover well due to inflammatory toxins from the bacteria. Are moisturizers for eczema/ dry skin incorporating antiseptic properties? Which antiseptics are now recommended for eczema children and how likely are these to irritate skin?
Dr Steve Xu: Absolutely, treating staph colonization is a big component of successfully treating atopic dermatitis. Moisturizers typically don’t have anti-bacterial ingredients. But, we do know that impaired or broken skin barrier facilitates the colonization and growth of staph. Thus, moisturizers play a big role in keeping the skin barrier intact so that staph can’t cause problems.
At least in the U.S., we hardly ever specifically recommend an ‘anti-septic’ moisturizer. It’s interesting to see that there are products out there marketed as such. We separate the use of moisturizers (barrier protection) and the elimination of colonizing bacteria (mupirocin ointment, bleach bathes). Typically for our patients, we always recommend moisturizers for skin barrier preservation but tend to be more reactive when it comes to recommending bleach bathes or mupirocin ointment at the sign of super infection (formation of pustules).
With that being said, lauric acid is certainly an ingredient that is becoming more and more popular. It is the key component in coconut oil, which has shown to have a broad range of antibacterial properties.
Long-story short, I think there’s probably a benefit from using antiseptics more regularly in managing atopic dermatitis. We know that the skin of eczema children have less anti-microbial peptides, natural bacteria fighting proteins produced by the skin. There’s no great head to head studies comparing coconut oil (moisturizer + anti-septic properties) vs. a regular moisturizer in managing atopic dermatitis. But, I think there is some benefit here that may be real for some patients that have a particular sensitivity to staph colonization.
Also, common over-the-counter topical antibiotics such as neomycin and bacitracin are notorious agents for causing allergic contact dermatitis. We typically do not recommend these for children with atopic dermatitis. In the United States, we prefer topical mupirocin (prescription only). This medication rarely causes allergic contact dermatitis compared to neomycin or bacitracin.
Age of Allergic Contact Dermatitis
In the article1, it was mentioned that studies have shown that there are different age (timing) where there is peak prevalence of contact allergy among children, being
0 – 3 years old – could be due to immature skin barrier, including lower lipid content, fewer natural moisturizing components, higher pH and thinner epidermis
6-7 years old
MarcieMom: Are there a certain group of children who is more likely to have contact dermatitis? Narrowing this further, is there a particular profile of eczema children who are more likely to also have contact dermatitis?
Dr Steve Xu: This is a great question. I think certainly, older children and adolescents will have had greater exposure to potential allergens over time. However, an allergic contact dermatitis can occur at any age including toddlers. I think the most important thing is to have a high index of suspicion for allergic contact dermatitis in children with atopic dermatitis.
Is your child’s atopic dermatitis not getting better despite the best therapy?
Is your child’s atopic dermatitis appearing in areas that it never appeared before?
Are there eczematous rashes that seem to happen in the same locations such as the belly button, neck, waistband or wrist? Do the rashes appear linear (straight) or rectangular?
We’ve had plenty of pediatric patients with stable atopic dermatitis that would inexplicably get worse or not respond to therapy. After patch testing, we would identify a common allergen such as nickel. The rashes won’t get better unless nickel is avoided.
In the article1, it was mentioned that the most “allergenic” corticosteroids are:
The least allergenic are those with halogenated C16-methylated molecules and in order of increasing potency:
Again, there is the possibility of children with atopic dermatitis using more topical steroids and therefore getting hypersensitive to it overtime.
MarieMom: The article mentioned classifying topical steroid creams using different groups, based on their likelihood of being contact allergens. The likelihood can be due to different molecular (steroid) structure, the other non-steroid ingredients in the prescription cream, how long it is used and how occlusive it is (topical steroid creams are not recommended with wet wraps as absorption rates are higher than intended when occluded).
MarcieMom: What are the common steroid creams prescribed for young children with eczema? And how likely will they cause contact dermatitis?
Dr Steve Xu: Overall, a true allergic contact dermatitis to topical steroids is quite rare. Aclomethasone and desoximethasone are both popular choices.
I will say that sometimes it’s better judicious to not always reach for the least hypo-allergenic topical steroid at first. In the vast majority of time, a children will not have a contact allergy to a topical steroid. If we reach for a hypo-allergenic topical steroid and a contact allergy does develop, we have less therapeutic options in the future.
MarcieMom: Thank you Dr Steve for your time to help with this series; really glad for this interview as it has certainly raised my awareness of contact dermatitis in children (where previously thought to be remote).
References: 1. Hannah Hill, Alina Goldenberg, Linda Golkar, Kristyn Beck, Judith Williams & Sharon E. Jacob (2016): Pre-Emptive Avoidance Strategy (P.E.A.S.) – addressing allergic contact dermatitis in pediatric populations, Expert Review of Clinical Immunology, DOI: 10.1586/1744666X.2016.1142373
Toxic shock syndrome is rare but life threatening, caused by bacterial toxins from staphylococcus aureus. Toxic Shock Syndrome commonly affects teens and young adults, from age 15 to 35 and majority, female.
What Causes Toxic Shock Syndrome?
Toxic Shock Syndrome is due the bacterial infection via the skin, vagina or pharynx into the bloodstream. While it is not uncommon for Staph bacteria to colonize the skin, a cut, surgery or wound in some individuals may lead to the bacteria entering the blood without immunity to fight it. The conducive environment for the toxin is protein-rich and oxygen, which is what the use of tampons during menstruation provides. Tampons with higher absorbency (polyester, carboxymethylcellulose and polyacrylate) increases the risk of TSS. The toxins can cross the vaginal wall to the blood stream, possibly through tear when inserting the tampon.
Symptoms of Toxic Shock Syndrome
Confusion, dizziness due to low blood pressure
Swelling and redness in mucous membrane
Diagnosis is made based on physical examination, blood or urine test or swaps from the cervix, vagina and throat.
Skin rash – generalized, flat and red (characterized by turning white when pressed)
Shock occurs when the blood pressure cannot be maintained
Skin rash disappears on recovery.
Skin on palms of hands and soles of feet flake and peel off.
Fingernails, toenails and hair may fall out.
Types of Toxic Shock Syndrome
Toxic Shock Syndrome due to bacteria Staphylococcus aureus
Streptococcal Toxic Shock Syndrome due to bacteria Streptococcus pyogenes
Treatment of Toxic Shock Syndrome
TSS is considered a medical emergency that required hospitalisation. An intravenous antibiotic will be prescribed to fight the bacteria infection, or medication to stabilize blood pressure and to prevent dehydration. Injections may also be given to suppress inflammation and increase body’s immunity. Also the cause of the bacterial infection will be removed, for instance, removal of the tampon or draining pus from the skin wound.
Complications of Toxic Shock Syndrome
If the internal organs are affected, it can lead to liver, kidney, heart failure, seizure and shock. Early detection of toxic shock syndrome has a much higher chance of recovery. The mortality rate is about 5-15% and rate of recurrence at 30-40%.
Toxic Shock Syndrome and Eczema
It is observed that patients recovering from TSS tend to develop chronic eczema. I couldn’t find literature on the likelihood of having TSS if one has eczema. I wonder if there’s increased risk since the skin of eczema patients tend to have staph bacteria colonization.
Prevention of Toxic Shock Syndrome
Certain precautions for menstruating female who uses tampon are to change the tampon every 4 to 8 hours and to use a low-absorbency tampon. Wash hands and keep skin cuts and wounds clean with frequent dressing change. TSS may recur, thus tampon should not be worn by those who had TSS before.
Anyone have experience with toxic shock syndrome? Do share, it will be useful to the rest of us and to be more aware of the risks.
Impetigo is a common bacterial infection for children ages 2 to 5, and more likely for a child with pre-existing skin condition such as eczema. Today’s article aims to find out more about impetigo, its signs (how to recognize it early), its treatment, prevention and the correlation between impetigo and eczema/atopic dermatitis.
What is Impetigo?
Impetigo is a skin infection that is caused by bacteria (i) Staphylococcus aureus or (ii) Streptococcus pyogenes (same as that causing strep throat). Methicillin-resistant Staphylococcus aureus (MRSA) also causes impetigo. Impetigo is contagious and affect preschoolers most often.
Should impetigo appear as large blisters, it is known as bullousimpetigo or non-bullous impetigo if they are crusted. Non-bullous impetigo is more common, often starting out as tiny blisters, then bursting to become wet patches of reddened weeping skin. It then form a yellowish crust.
Signs of Impetigo
Blisters or sores on the face (nose, mouth), neck, hands, forearms and diaper area – these areas are within easy ‘scratching’ reach and often carries more bacteria from contact with surfaces with bacteria. The blisters burst and form a yellowish crust. Impetigo can also present as folliculitis, whereby the hair follicles also blister and burst to become wet patches. Impetigo may also be itchy and be painful if it occurs around lymph nodes. In a study, the areas most commonly infected by impetigo are the head and neck (65.4%), followed by 19.6% on an upper extremity and by 7.5% each on the trunk and a lower extremity.
Treatment of Impetigo
For localized, yet to spread impetigo, antibiotic ointment can help (mupirocin (Bactroban) or fusidic acid) . For more widespread impetigo, oral antibiotic is prescribed for a faster recovery (few days versus few weeks) and control of the blisters. The area has to be washed and covered up to prevent scratching and spreading the bacteria to other parts of the body. Generally, after 48 hours of antibiotic treatment, the child may be cleared to return to preschool.
Prevention of Impetigo
As impetigo is caused by bacteria, good hygiene such as hand-washing, not touching other surfaces, biting fingers, scratching can help prevent it. For children with eczema, it is good to bring them for swimming, consider cleaning with chlorhexidine or bleach bath in order to keep the bacteria count low and minimize the chance of skin infection. As there is staph bacteria present in the nose, children should refrain from ‘digging’ nose and touching the rest of the body. Fingernails should be kept short and ensure no sharing of towels, bed linen or clothing with other family members.
Impetigo and Eczema
Impetigo is more likely to affect children with already a weakened skin barrier, either generalized as in eczema or localised as in insect bites, cuts or rashes from contact allergens. As it is spread by contact with the bacteria, it most often affects children who scratch, thus often affecting eczema kids. For children in hot and humid climate/ during summer, the likelihood of impetigo infections is higher (higher chance of insect bites, scratching). Eczema skin is more often colonized with staph bacteria and for those with history of eczema herpeticum, the impetigo infection may be via MRSA bacteria.
All in, impetigo is a condition that parents with eczema kids should definitely be aware of. Especially if your child, like mine, live in hot, humid climate, goes to preschool and scratches/bites and simply can’t follow good hygiene! (did I hear a ‘bummer’ from one of you?)
This is part of a quarterly round-up of some of the recent eczema-related studies, so that we can be aware of possible treatments and their efficacy (and I can also keep myself updated with the latest eczema research!)
Today’s topic is on Staph Bacteria, should we Reduce it? Staph, short for Staphylococcus aureus, is a bacteria that is frequently found on the skin of eczema patients. I have wrote about staph bacteria from as early as 2011, covering topics from:
At the same time, I have been encouraging parents to bring their children for swimming or to clean the child’s eczema skin with chlorhexidine, with the intention of reducing the staph bacteria which promote skin inflammation via the provocation of mast skin cells. My purpose today is to update on the literature behind staph bacteria, in the hope of knowing if we ought to be more vigilant at reducing the staph bacteria on our child’s skin.
What is Staph Bacteria?
Staph is short for staphylococcus aureus, a very resilient bacteria found on the skin that can survive in dry condition and on dry skin with little oxygen. It tends to involve areas that are warm and moist especially such as skin near mucous membranes such as the nose, mouth, genitals and anal area. It is found in about 25-30% of healthy adults who are known as carriers and generally does not cause an infection in those with otherwise healthy skin. However, in almost 90% of eczema patients, staph bacteria colonizes their skin.
What harm does Staph cause?
According to a research paper, the staph bacteria “causes immune-system cells in the skin to react in a way that produces eczema-like rashes. The release of the molecule, called delta toxin, by staph bacteria caused immune-related mast cells in the skin to release tiny granules that cause inflammation”.
What’s the studies on treatment involving the active reduction of staph bacteria?
We are interested in this, obviously, it is important to know if the measures that we are taking in the care of our child’s eczema skin is effective. Based on the studies I looked up on PubMed from 2013 onward:
Bleach bath is effective in eczema treatment, via reduction of staph bacteria (here)
Confirmation that children with eczema have staph bacteria colonization on their skin (here), likewise for adults (here, in particular it was hypothesized that staph bacteria colonization may have facilitated the penetration of allergens into the skin, triggering rash)
Update for August 2015 study which contrary to previous studies, showed that a four-week, twice-weekly regime of bleach baths is no more effective than water in a double-blinded, placebo-controlled cross-over trial.
Staph bacteria associated with higher severity of eczema (here)
A number of studies mentioned the concern over MRSA, and that prescription such as fusidic acid may lead to the bacteria being resistant to treatment (here).
Have you tried any of the staph bacteria reduction tips for your child? Is it effective? Do share in the comments, thank you!
A quick post on the latest study published in the above New England Journal of Medicine on the effectiveness of chlorhexidine soap on the decolonization of MRSA in hospitals.
1. Investigating if targeted decolonization or universal decolonization are more effective in hospitals.
Why hospitals? Hospitals is one of the common areas where staph bacteria S. aureus strive, due to it being a confined area with patients with infection. Read Dr Clay’s Q&A #2 to avoid hospitals if your child has eczema.
What’s the big deal of MRSA decolonization?
MRSA is a big deal, because it is a particular strain of staph bacteria that is resistant to commonly prescribed antibiotics such as methicillin, floxacillin, lactamase-resistant pencillin and amoxicillin. This puts the patient at a high risk of complications from MRSA infection that cannot be promptly treated. Read this post to understand MRSA. It is a big deal for eczema patients because staph bacteria colonization is common on eczema skin, and thus poses the risk of MRSA infection.
The study from 3 hospitals (including 74 ICUs and 74,256 patients) showed that universal decolonization is more effective than targeted. Which means – eliminate the need to screen patients for MRSA, but instead have all ICU patients use chlorhexidine soap and mupirocin ointment. What’s chlorhexidine? A chemical that can kill stap bacteria – implications for eczema?
3. Implications for Eczema?
I think it reinforces the active washing with chlorhexidine reduces bacteria infection. I always wipe my child’s eczema skin with chlorhexidine, to remove staph. Staph promotes skin inflammation, read more here, and here on how resistant Staph is.
This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients. I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatology and pathology and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.
Staph bacteria, including MRSA, are spread from skin-to-skin or by contact with surfaces and objects. Staph bacteria present in mucous lining of the nose can be passed to another if the other person touches the mucus from the former’s sneezes (and kindly not dig your nose!). Measures such as hand washing, disinfecting, particularly on surfaces such as doorknobs, mobile phone and keyboards, kill the Staph bacteria.
Infection Prevention and Hygiene Tips for Kids
Marcie Mom: Dr. Clay, here are a series of practical questions on regular cleaning and hygiene!
1. For cleaning of door knobs/mobile phones – how regular should the cleaning be? And is any disinfectant effective against Staph bacteria?
Dr. Clay: The common household antiseptics that contain bleach and other products, such as Lysol, are very effective at killing Staph. There is no “right” answer to how frequently to clean these areas, but if there is a person at high risk of getting an infection or becoming colonized with MRSA, such as a child with eczema, perhaps as often as once or more per day might be a good idea.
2. A hospital setting or being in a confined area with a patient with infected wounds, is a venue with a higher rate of MRSA.
Should a child not be brought to a hospital at all, especially a child with eczema skin?
Dr. Clay: Yes, if the eczema is flared, it would probably be wise to avoid such settings. If for some reason the child must be in those areas, I would strongly recommend that he or she wear protective clothing, such as a gown, and consider taking a bleach bath or shower afterward.
3. Towels should not be shared but washed with detergent and preferably warm water.
What is the temperature a washing machine ought to be set to kill Staph bacteria?
Dr. Clay: The temperature is not the most important aspect of killing the bacteria, but rather the presence of the detergent – especially if it contains bleach is very important. Even if the clothing is washed in cool water, if it contains bacteria-killing detergent, that will be effective. Most washing machines have a hot/warm cycle, but the temperature of the water is not hot enough alone to kill bacteria.
4. Pets can also be infected with Staph bacteria and pass to humans through contact.
Should regular checking of the pet be conducted for Staph bacteria?
Dr. Clay: Yes, especially if there is a child at home with eczema. Most pets that are infected with Staph have some sort of skin compromise like crusting and oozing, and a veterinarian should evaluate those. Just as with humans, washes with bleach-containing products coupled with antibiotics are quite effective.
5. For someone who had a prior Staph infection, is he/she more prone to a repeat case?
Dr. Clay: Yes. Unfortunately, this indicates that the person is prone to get Staph and that their body chemistry is conducive to Staph colonization.
Bleach Bath & Alternative Preventive Measures
Bleach bath has been shown to be effective in reducing Staph bacteria, more in this post.
How does the bleach act against the bacteria on the skin? Kill it and it’s drained with the water?
Dr. Clay: Bleach differs from antibiotics in its killing mechanism as it acts to physically destroy the bacterial cell wall and proteins. Antibiotics interact with the proteins and nucleic acids to cause the bacteria to make abnormal cell structures. As such, they can develop resistance. Once the bacteria are killed with bleach, the residual cell structures are no longer viable, and yes, they will degenerate and be washed away.
For parents who are resistant to bleach bath (like me), I use chlorhexidine.
How much chlorhexidine to put on the cotton pad (soaking wet or squeezed dry wet) and how many ‘swipes’ are required to kill the bacteria?
Dr. Clay: Chlorhexidine is also effective at killing bacteria and basically, all one needs is to coat the area and rinse with water. There is no “right” amount to use, just use enough to cover the area and wash it off. Different products come with different instructions, so follow those as it may be necessary to leave it on a bit longer before washing. Chlorhexidine is not supposed to be used on the head and neck or in the groin area, however, and unfortunately, these are areas where Staph thrives. For this reason, bleach-containing products like CLn® BodyWash, which can be used in those areas, is a very good alternative. It’s much easier to use than a traditional bleach bath and is much more cosmetically elegant.
Are there other alternatives? Especially for a child with eczema who ought to avoid frequent hand washing with soap?
Dr. Clay: As noted above, a bleach-containing product such as CLn® BodyWash could help to decrease the use of harsher products because of their efficacy in killing bacteria such as Staph and MRSA, which would lessen the risk of causing irritation. For general cleansing, mild cleansers like Cetaphil can be used instead of soap and water, which also lessens the risk of irritation – although, this has no antibacterial effect.
MarcieMom: Thank you so much Dr Clay Cockerell for teaching us lots on how to manage the bacteria on our child’s skin. I’ve learned much in this series and I’m sure many parents do and appreciate your advice!
This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients.I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatologyand pathology and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.
A common treatment for Staph infection is the use of an antibiotic either topical or oral. Pus may also be drained (only by doctor!). Dr. Clay, what are the common types/names of antibiotics prescribed for Staph infection? And if an antibiotic cream is prescribed, what is the frequency and duration of topical application? Should a parent consult the doctor again if there’s no improvement within the first two days (for possibility of different strain of bacteria involved)? Can a parent apply the same cream the next time a similar-looking rash occurs on the child’s skin?
Dr. Clay: There are a number of antibiotics that are effective against Staph, but unfortunately, many strains of Staph are now resistant to the antibiotics that have been used for years. The most commonly used antibiotics are in the penicillin family, and one of the best is methicillin. Cephalosporins, such as cephalexin, are also good for sensitive strains. Topical antibiotics include bacitracin, Neosporin and mupirocin (Bactroban). These are usually applied two to three times a day. It usually takes several days for improvement to be noted, and there may be redness that lasts for several more days than that. There should be no further spreading of the process, and the pain and redness should start to resolve in two to three days.
What if there is no improvement after treatment?
If there is no improvement, it should be checked by a doctor as it is possible that it is being caused by another rare organism or fungus, or it may be a sign that the patient’s immune response is too weak to help eradicate it with a topical antibiotic alone. In general, if the patient is doing well and develops a similar process, the family can try to treat topically at first. If it does not improve in a few days, the doctor should be notified.
A worrying trend is that there is a strain of Staph bacteria, namely the MRSA, which has developed resistance against the commonly prescribed antibiotics noted above. As explained on Dermnet NZ, there is a mec gene in the bacterium that “alters the site at which the methicillin binds to kill the bacteria.” As such, the binding is rendered ineffective, and the MRSA cannot be killed by antibiotics such as methicillin, floxacillin, lactamase-resistant pencillin and amoxicillin.
What are the antibiotics that can be given to a child that can kill the MRSA?
I read that Vancomycin is one such antibiotic, but there are also strains of Staph bacteria that have become resistant to it. What about Bactrim DS (double-strength sulfamethoxazole trimethoprim)?
Dr. Clay: Yes, vancomycin is a commonly used antibiotic that is effective against MRSA, but it cannot be taken orally. If the infection is relatively mild, we generally use Bactrim DS, as it can be taken by mouth and is effective. It is also important to supplement this with measures to try to eradicate it from the skin such as the use of bleach-containing cleansers, like CLn® BodyWash.
MarcieMom: Thank you Dr Cockerell, next week we shall learn about prevention – definitely beats having to treat a staph infection!
This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients. I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatologyand pathology and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.
Last week, Dr. Clay Cockerell gave us some basics about the type of bacteria found on our skin. This week, we will discuss Staphylococcus aureus (“Staph”) and other harmful bacteria.
Staphylococcus aureus worsens Eczema Skin
Staph aureus is not normally found on our skin, but in some people such as those who are colonized, it may be. When it is, it tends to involve areas that are warm and moist especially such as skin near mucous membranes such as the nose, mouth, genitals and anal area. It is found in about 25-30% of healthy adults who are known as carriers and generally does not cause an infection in those with otherwise healthy skin. It is a very resistant bacterium and it can survive in dry conditions such as on dry skin and with little oxygen.
Marcie Mom: Dr. Clay, I understand that Staph is a main factor causing skin inflammation in eczema skin.
Can you detail for us where Staph bacteria reside, how it penetrates and attacks the (i) skin and (ii) body of our child with eczema?
Dr. Clay: As noted in the first post of this series, Staph likes warm, moist, dark areas like the nose and groin, which are known as “reservoir” sites where it resides. In patients with eczema, it can affect any area of the skin that is compromised or affected with the dermatitis. Because the skin is compromised, it does not have a normal barrier, and the immune response is abnormal. The Staph grows in the skin and releases toxins that cause inflammation, which further worsens the eczema.
Staph bacteria likes warm, moist, dark areas like the nose and groin
It can begin growing in the skin and establish infection in the form of boils, cellulitis and folliculitis (“pus bumps”) in these individuals, as well. Rarely, it can actually enter the lymph and blood vessels and spread throughout the body, but it tends to remain localized at the site of entry.
Streptococcus Pyogenes Bacteria & Skin Infections
Marcie Mom: Another harmful one is the streptococcus pyogenes bacteria (“strep”), found in our throat and skin and in about 20% of healthy adults. Staph or strep bacteria can lead to skin infections such as folliculitis, furunculosis, impetigo, cellulitis, MRSA and Staphylococcal scalded skin syndrome (read more here). A skin culture can be performed which will diagnose which bacteria is present on the skin.
Marcie Mom: There are various symptoms of bacterial skin infection listed below, can you share with us the severity of the infection, e.g. when a parent ought to (i) seek a general practitioner’s consultation or (ii) rush to emergency?
Dr Clay’s Skin Infection Symptoms
Symptoms – itchy red rashes. This is the most common manifestation of eczema and may or may not be infected with bacteria. This can be treated at home using the prescribed treatment regimen.
Symptoms – skin turns painful, warm to touch/tenderness, swelling. This is a sign of a skin infection and needs to be seen by a doctor soon. If there is fever, this is something that a doctor should be notified about and an oral antibiotic should be started. It probably does not require a visit to an emergency room, but it should be called to the attention of a doctor who would evaluate the severity and might recommend that the patient be seen. These infections can arise at any time during the course of the disease.
Symptoms – infected area is filled with pus/blister/boil. As above, this is a sign of an infection and should be treated with an antibiotic. These are usually localized, but may require drainage. A caregiver should be notified who will prescribe a regimen such as applying warm compresses, topical antibiotics and possibly oral antibiotics. Generally, the patient should be seen soon and a culture performed. This is not usually an emergency, but if there is fever or redness that is spreading like above, it might require more urgent attention than a follow-up in a clinic.
Symptoms – lymph node on neck or armpit becomes protruding/ sore. This is also another sign of infection and would generally be treated like cellulitis. This is not usually an emergency, but would require antibiotics and culture.
Symptoms – fever/ chills, low blood pressure. This is a sign of a serious systemic infection, and the patient should be taken to an emergency room by an ambulance. This could be a manifestation of Toxic Shock Syndrome, which can be caused by some forms of Staph, or could possibly be necrotizing fasciitis, which might need emergency surgery.
MarcieMom: Thank you Dr Cockerell for helping us understand which symptoms we ought to be aware of. Next week, we will explore the treatment options and learn more about MRSA.
The Invisible Factor affecting your Child’s Eczema Rash – Skin Bacteria
This is a 4-week series focused on bacteria found on our skin, in particular Staphylococcus aureus, a bacterium that can lead to infection and complications in eczema patients.I’m honored to have Dr. Clay Cockerell, former clinical professor of dermatology and patholgy and the former director of the Division of Dermatopatholgy at University of Texas Southwestern Medical Center in Dallas, Texas, to help in this series.
More on Dr. Cockerell – Dr. Clay Cockerell was the president of the American Academy of Dermatology in 2005. He is a renowned medical educator having overseen an educational program designed to train the next generation of dermatologists and dermatopathologists and the author of numerous papers and textbooks. He is a board-certified dermatologist and dermatopathologist licensed in many states throughout the U.S.His clinical expertise is in skin disorders and his passion has led him to co-found TopMD Skin Care, the company behind CLn® BodyWash.
Your Child has both Good and Bad Bacteria on Eczema Skin
Our skin is home to about 1 trillion microscopic organisms such as bacteria and fungi, and not all are bad – some are beneficial to us and some are harmless, but some are harmful like the Staphylococcus aureus bacterium (“Staph”) and Streptococcus pyogenes (“Strep”) that can cause skin infections. You can read more about the Human Microbiome Project of National Institutes of Health in this interview with Elizabeth Grice.
Marcie Mom: Dr. Clay, I read from this table that the bacteria commonly found on our skin are (1) Staphylococcus epidermidis, (2) Staphylococcus aureus, (3) Streptococcus pyogenes (4) Corynebacteria and (5) Mycobacteria.
Which bacteria are good for us (for instance, prevent colonization of harmful bacteria) and which bacteria are harmful?
Dr. Clay: Staphylococcus epidermidis is part of the normal bacterial flora that lives on our skin and is a beneficial bacterium. In fact, they serve in many ways to “police” the skin and prevent dangerous ones such as S. aureus and S. pyogenes from growing and “setting up shop”. These latter two may cause boils, folliculitis, cellulitis and erysipelas, all examples of skin infections.
Corynebacteria exist in several different species. C. acnes lives in hair follicles normally, but plays a role in the development of acne in acne-prone individuals. Other forms of Corynebacteria can also cause more serious infections such as C. minutissimum, which causes pitted keratolysis and juvenile plantar dermatosis, and C. diphtheria, which can cause cutaneous diphtheria, a rare form of cellulitis. There are also many different species of Mycobacteria, some of which are harmless and live in certain areas of the body such as the groin (M. smegmatis).
Others are harmful and can cause cutaneous tuberculosis and atypical mycobacterial infections such as Swimming Pool granuloma (M. marinum) and infections acquired from getting pedicures when exposed to infected water in nail salons (M. fortuitum).
Do We Need More Good Bacteria?
Most bacteria tend to reside in moist areas of skin, along skin folds. I read that diet, health, age and environment also affect the amount of bacteria on our skin. Let’s tackle the good bacteria on our skin first – is there anything that one can do (and should one try) to increase the amount of good bacteria on our skin?
Conversely, will frequent hand washing and use of sanitizers and anti-septic sprays remove good bacteria that our body needs?For a child whose immunity has yet to be fully developed, should he or she be washing hands more frequently or less than an adult?
Dr. Clay: The best way to increase the “good” bacteria is to have good hygiene, which prevents exposure to the “bad” bacteria (i.e., wash with a good soap and water and use hand sanitizers periodically). The good bacteria will naturally grow on your skin and live in harmony with our bodies naturally, as our body has certain factors, such as local immunity and chemicals on the skin surface, that create just the right environment.
Bacteria Population and Hand Washing
Bacteria multiply exponentially, so when its population is temporarily decreased, as after the use of hand cleanser, it re-grows quite quickly and returns to its normal concentration. The only way to truly “sterilize” so that the normal bacteria would not return would be to wash many, many times a day and even then, it is virtually impossible to get the skin totally sterile. In fact, individuals who do over-wash often cause significant skin irritation, which paradoxically can cause the “bad” bacteria to enter and colonize the skin and even cause an infection.
Staph Bacteria Colonizes Eczema Skin
There are individuals who have certain skin diseases that predispose them to become colonized with “bad” bacteria like Staph, especially those with atopic dermatitis, also known as eczema. These patients need to use more aggressive measures to get rid of these bacteria, as they can worsen the skin condition and lead to more serious infections. These patients often require systemic antibiotics or topical antibacterial agents including bleach, as administered in bleach baths, or bleach-containing body washes like the one I have been involved in developing, CLn® BodyWash, which can be used in a shower also.
Children don’t really need to wash their skin more than adults, as their immunity to bacteria develops very soon after birth. In fact, children’s skin can be more sensitive than adult skin, so care should be taken not to over wash with harsh soaps and detergents. Skin in elderly individuals also is less able to tolerate dryness, so the same caution should be taken by them, too.
Children and Elderly’s Skin should not be over-washed with harsh soaps
People who are Staph carriers (i.e. abnormally harbor Staph on their skin) are prone to developing boils and other infections and can spread the Staph to family members. They, too, should take measures to try to decrease the spread of Staph by using topical antibiotics and antiseptic washes.
MarcieMom: Thank you Dr Cockerell for the detailed explanation of the various bacteria on our skin. Next week, we will discuss specifically on staph bacteria.
Published in May 2009 Pediatrics Journal was the findings of a bleach bath study conducted on 31 children, aged 6 to 17 months, with moderate to severe eczema. The children had staph (see this post to learn about staph), which is a very resilient bacteria on the skin that can cause infection. Half the children were soaked 5 to 10 minutes in a bleach bath twice a week, while the other half in a placebo bath. The children who were soaked in the bleach bath showed decreased severity of eczema within 3 months. The diluted bleach bath act like a antiseptic, which can remove the bacteria. Before trying this on your own, do check with your baby’s doctor and also note the following:
1. Dilute the bleach and don’t apply bleach directly onto skin. Bleach is an irritant to the skin, so do check with your doctor on the preparation of the bath. For the above study, it’s ¼ cup bleach diluted with 40 gallons of lukewarm water. The concentration of sodium hydrochlorite in the bleach should not be more than 6%. Learn more about bleach bath and its effect on skin pH in interview with dermatologist Cheryl Lee MD
3. The neck and head was not in the water for the study. It was published online though that the doctor of this study, Dr Amy Paller, suggested closing eyes and submerging head into the bath to clear the bacteria. I’m not sure about this as my baby Marcie keeps drinking her current oatmeal bath!
4. A 14-day oral antibiotic was given at the same time during the study, and moisturizing too. This meant that bleach bath is not a standalone treatment (in fact, bleach can dry/irritate the skin, so do dilute and moisturize a lot).
5. Bleach bath should not be used for cracked skin, and consult your doctor first (I know my baby’s doctor recommended swimming and octenisan (2018 update: a more moisturizing antiseptic wash alternative chlorhexidine), which also serve to remove the staph bacteria).
2014 update: Read my interview with Dr Cheryl Lee on eczema skin and pH (including a Q&A on bleach bath)
2015 update: Read my interview with Dr Lawrence F Eichenfield (in collaboration with American Academy of Dermatology) on eczema bleach bath
My take is I don’t dare and won’t try bleach bath, since chlorhexidine (antiseptic) had worked for my baby. Swimming had also worked for her, even when we only brought her weekly (as opposed to her doctor’s advice to bring her 3 times/week). Do you dare to try the bleach bath on your child? If you have, do let us know how it went, thanks!
This is a 4-part (a little more technical) series inspired by a review article “Features of childhood atopic dermatitis” by Hugo Van Bever and Genevieve Illanora. The article summarizes 4 players involved in atopic dermatitis, and I’ve tried to understand whatever I could from the article and other research papers published online and hopefully digested the information accurately for you to read.
What is Staph?
Staph is short for staphylococcus aureus, a very resilient bacteria found on the skin that can cause infection if it penetrates the skin. More than 90% of the people with eczema has staph versus less than 10% of people without eczema. Read more about staph bacteria on eczema skin in this interview with Dr Clay Cockerell, former president of American Academy of Dermatology.
One more reason not to scratch
Scratching gives a feel-good feeling to your child as written in this post, but it’s really bad. Scratching damages the skin barrier and makes it very easy for staph to penetrate. As written in the article “Features of childhood atopic dermatitis”, staph increases IgE production, activate native T-cells by its superantigens and damage skin by its proteases.
IgE are antibodies that catalyzed the protective cells of the immune system to lock on to the antigen, see this post on immune system). Superantigens are toxins released by staph, that causes skin inflammation. Staph also results in less protein that is used to fight infection.
How do you know if your child has Staph?
Children with eczema are prone to staph bacteria, so chances are very likely there is staph on the skin but it may or may not be visible in the form of skin inflammation. If there is honey-colored crusts, pus-filled blisters, red scaly patches, swelling that is warm to the touch or fever, it’s likely that staph has already caused skin infection.
So, how to get rid of the Staph bacteria?
Marcie’s doctor Prof Hugo Van Bever recommended using chlorhexidine before applying steroid cream for Marcie. I told him during the consultation that I only use chlorhexidine (antiseptic solution) when Marcie’s rashes is persistent and red (like in the picture). However, he said that the bacteria is not visible to human eye thus it’s a good practice to clean the skin before applying steroid.
I also read that some paediatrician recommended diluted bleach bath as the bleach can remove the bacteria from the skin. Prof Hugo recommended swimming for Marcie. The idea is that people with eczema typically suffers from bacteria colonization, so remove the bacteria first and if need be, apply steroid which is more effective without the bacteria (of course, moisturizing is a must).