Interventions to reduce Staphylococcus aureus in the management of atopic eczema.
BACKGROUND
Staphylococcus aureus can cause secondary infection in atopic eczema, and it may promote inflammation in eczema that does not look infected. Many antimicrobial products exist for eczema, but it is unclear if they work or if they promote bacterial resistance.


OBJECTIVE
To assess the effects of interventions to reduce Staphylococcus aureus for treating infected or uninfected atopic eczema.


METHODS
We searched the Cochrane Skin Group Specialised Register (March 2008), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 1, 2008), MEDLINE (OVID) (from 2002 to March 2008), EMBASE (OVID) (from 2002 to March 2008), Ongoing trials registers (March 2008). References from trials and reviews were searched, pharmaceutical companies were contacted for unpublished trials. There were no language restrictions.


METHODS
Randomised controlled trials (RCTs) of people with atopic eczema who have been treated with a product intended to reduce S. aureus on the skin.


METHODS
Two people independently performed the study selection, data abstraction and quality assessment.


RESULTS
We included 21 studies (1018 participants) covering 7 treatment categories. Most studies were poorly reported and study differences limited pooling of results. Adverse effects were especially poorly reported, and only one study reported the emergence of resistant bacterial strains following oral antibiotics. Oral antibiotics were not associated with benefit in non-infected (2 trials, 66 participants) or infected eczema (1 trial, 33 participants). We did not find any benefit for antibacterial soaps (1 trial, 50 participants), or antibacterial bath additives (2 trials, 41 participants), or topical antibiotics/antiseptics (4 studies, 95 participants). Adding antibiotics to topical corticosteroids reduced numbers of Staphylococcus aureus in 4 trials (302 participants), but there was no evidence of any clinical benefit in 9 trials involving 677 participants: betamethasone plus neomycin vs clobetasol (MD 1.2; 95% CI 0.25, 2.15), prednicarbate plus antimicrobial vs prednicarbate (RR 0.64; 95% CI 0.25, 1.68), or betamethasone valerate plus gentamicin vs betamethasone (RR 0.31; 95% CI 0.07, 1.35). One trial (30 participants) showed no significant improvement in eczema for those using silver textiles (RR 2.67; 95% CI 0.98, 7.22), despite using 10 times the amount of topical steroids.


CONCLUSIONS
We failed to find clear evidence of benefit for antimicrobial interventions for people with atopic eczema, despite their widespread use. This does not necessarily mean they do not work because the studies were small and poorly reported. Further large studies with long-term outcomes and clearly defined participants are urgently required.
Birnie
Andrew J
AJ
Dermatology, Nottingham University Hospitals NHS Trust, Derby Road, Queen's Medical Centre Campus, Nottingham, UK, NG7 2UH. birnie@doctors.net.uk
Bath-Hextall
Fiona J
FJ
Ravenscroft
Jane Catherine
JC
Williams
Hywel C
HC
D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use; D000891:Anti-Infective Agents, Local / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D003020:Clothing; D003876:Dermatitis, Atopic / Q000188:drug therapy* / Q000382:microbiology; D024881:Drug Resistance, Bacterial; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D018030:Silver Compounds / Q000627:therapeutic use; D012915:Soaps / Q000009:adverse effects / Q000627:therapeutic use; D013207:Staphylococcal Skin Infections / Q000188:drug therapy*; D013211:Staphylococcus aureus
D000900:Anti-Bacterial Agents; D000891:Anti-Infective Agents, Local; D000935:Antifungal Agents; D018030:Silver Compounds; D012915:Soaps