Interventions to reduce <i>Staphylococcus aureus</i>
 in the management of atopic eczema: an updated Cochrane review

Bath‐Hextall, Fiona; Birnie, Andrew; Ravenscroft, Jane; Williams, Hywel C

doi:10.1111/j.1365-2133.2010.09743.x

Cited by 183 publications

(99 citation statements)

References 26 publications

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“…However, it must be noted that the cause and effect relationship between skin microbiota dysbiosis and AD remains incompletely elucidated 68. Currently, no evidence of benefit of antimicrobial interventions directed at reduction of Staphylococcus in patients with AD exists, only in secondarily impetiginized AD 69, 70, 71. As multiple studies included in this review indicate that the skin microbiota within an individual patient varies over time 60, 61, 63, 64, there is need for longitudinal, frequent sampling and standard analysis studies.…”

Section: Discussionmentioning

confidence: 99%

A systematic literature review of the human skin microbiome as biomarker for dermatological drug development

Kolk

Wall

Balmforth

et al. 2018

Brit J Clinical Pharma

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AimsTo explore the potential of the skin microbiome as biomarker in six dermatological conditions: atopic dermatitis (AD), acne vulgaris (AV), psoriasis vulgaris (PV), hidradenitis suppurativa (HS), seborrhoeic dermatitis/pityriasis capitis (SD/PC) and ulcus cruris (UC).MethodsA systematic literature review was conducted according to the PRISMA guidelines. Two investigators independently reviewed the included studies and ranked the suitability microbiome implementation for early phase clinical studies in an adapted GRADE method.ResultsIn total, 841 papers were identified and after screening of titles and abstracts for eligibility we identified 42 manuscripts that could be included in the review. Eleven studies were included for AD, five for AV, 10 for PV, two for HS, four for SD and 10 for UC. For AD and AV, multiple studies report the relationship between the skin microbiome, disease severity and clinical response to treatment. This is currently lacking for the remaining conditions.ConclusionFor two indications – AD and AV – there is preliminary evidence to support implementation of the skin microbiome as biomarkers in early phase clinical trials. For PV, UC, SD and HS there is insufficient evidence from the literature. More microbiome‐directed prospective studies studying the effect of current treatments on the microbiome with special attention for patient meta‐data, sampling methods and analysis methods are needed to draw more substantial conclusions.

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Section: Discussionmentioning

confidence: 99%

A systematic literature review of the human skin microbiome as biomarker for dermatological drug development

Kolk

Wall

Balmforth

et al. 2018

Brit J Clinical Pharma

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“…27 A recently updated Cochrane review 28 of antimicrobial interventions for people with eczema, which included 26 studies and 1229 participants, found that most studies were small and of poor quality, and that although there was evidence that interventions reduced the presence of S. aureus on the skin, none of the studies showed any meaningful clinical benefit from antibiotics or other antimicrobial interventions, for either clinically infected or non-infected eczema. The authors concluded that 'Their continued use should be questioned in such situations, until better and longer-term studies show clear evidence of clinical benefit'.…”

Section: Use Of Antimicrobial Treatments For Eczemamentioning

confidence: 99%

“…The authors concluded that 'Their continued use should be questioned in such situations, until better and longer-term studies show clear evidence of clinical benefit'. 28 This is important not only because of the need to identify effective treatments for children with eczema, but also to reduce the use of ineffective treatments currently being prescribed. Clinical experts estimate that children in the UK experience approximately 900,000 eczema flares a year, and that approximately 40% of them are treated with topical antibiotics.…”

Section: Use Of Antimicrobial Treatments For Eczemamentioning

confidence: 99%

A randomised placebo-controlled trial of oral and topical antibiotics for children with clinically infected eczema in the community: the ChildRen with Eczema, Antibiotic Management (CREAM) study

Francis

Ridd

Thomas-Jones

et al. 2016

Health Technol Assess

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BackgroundSecondary skin infection is common during eczema exacerbations and many children are treated with antibiotics when this is suspected, although there is little high-quality evidence to justify this practice.ObjectiveTo determine the clinical effectiveness of oral and topical antibiotics, in addition to standard treatment with emollients and topical corticosteroids, in children with clinically infected eczema.DesignMulticentre randomised, double-blind, placebo-controlled trial.SettingGeneral practices and dermatology clinics in England, Wales and Scotland.ParticipantsChildren (aged 3 months to < 8 years) with a diagnosis of eczema (according to U.K. Working Party definition) and clinical suspicion of infection.Interventions(1) Oral flucloxacillin and topical placebo; (2) topical fusidic acid (Fucidin®, Leo Laboratories Limited) and oral placebo; and (3) oral and topical placebos, all for 1 week.Main outcome measuresPatient-Orientated Eczema Measure (POEM) at 2 weeks (assessing subjective severity in the week following treatment).ResultsWe randomised 113 children (36 to oral antibiotic, 37 to topical antibiotic and 40 to placebo), which was fewer than our revised target sample size of 282. A total of 103 (92.0%) children had one or more clinical features suggestive of infection and 78 (69.6%) children hadStaphylococcus aureuscultured from a skin swab. Oral and topical antibiotics resulted in a 1.52 [95% confidence interval (CI) –1.35 to 4.40] and 1.49 (95% CI –1.55 to 4.53) increase (worse subjective severity) in POEM score at 2 weeks, relative to placebo and controlling for baseline POEM score. Eczema Area and Severity Index (objective severity) scores were also higher (worse) in the intervention groups, at 0.20 (95% CI –0.12 to 0.52) and 0.42 (95% CI 0.09 to 0.75) for oral and topical antibiotics, respectively, at 2 weeks. Analyses of impact on the family, quality of life, daily symptom scores, and longer-term outcomes were all consistent with the finding of no or limited difference and a trend towards worse outcomes in the intervention groups. Sensitivity analyses, including adjusting for compliance and imputation for missing data, were consistent with the main findings.ConclusionsOur data suggest that oral and topical antibiotics have no effect, or a harmful effect, on subjective eczema severity in children with clinically infected eczema in the community. The CIs around our estimates exclude a meaningful beneficial effect (published minimal clinically important difference for POEM is 3.4). Although most patients in this trial had features suggestive of infection andS. aureuson their skin, participants primarily had mild–moderate eczema and those with signs of more severe infection were often excluded. Clinicians should consider avoiding oral and topical antibiotic use in children with suspected infected eczema in the community who do not have signs of ‘severe infection’. Further research should seek to understand how best to encourage the use of topical steroids and limit use of antibiotics in those with eczema flares without signs of severe infection, as well as developing tools to better phenotype eczema flares, in order to better define a population that may benefit from antibiotic treatment.Trial registrationEuropean Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2011-003591-37 and Current Controlled Trials ISRCTN96705420.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…3 However, a systematic review of antistaphylococcal interventions for AD did not show any convincing clinical improvements in patients with AD, despite quantitative reduction in skin bacterial load. 4 Another hypothesis for AD chronicity is the involvement of immune mechanisms against self-components. Two main observations have led to such a hypothesis.…”

mentioning

confidence: 99%

Does “autoreactivity” play a role in atopic dermatitis?

Tang

Bieber

Williams

2012

Journal of Allergy and Clinical Immunology

138

121

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Interventions to reduce Staphylococcus aureus in the management of atopic eczema: an updated Cochrane review

Cited by 183 publications

References 26 publications

A systematic literature review of the human skin microbiome as biomarker for dermatological drug development

A systematic literature review of the human skin microbiome as biomarker for dermatological drug development

A randomised placebo-controlled trial of oral and topical antibiotics for children with clinically infected eczema in the community: the ChildRen with Eczema, Antibiotic Management (CREAM) study

Does “autoreactivity” play a role in atopic dermatitis?

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