Atopic dermatitis: Topical antimicrobials and antiseptic recommendations

  • Except for bleach baths with intranasal mupirocin, no topical antistaphylococcal treatment has been shown to be clinically helpful in patients with AD, and is not routinely recommended. 

Level of Evidence: IStrength of Recommendation: A

  • In patients with moderate to severe AD and clinical signs of secondary bacterial infection, bleach baths and intranasal mupirocin may be recommended to reduce disease severity.

Level of Evidence: II Strength of Recommendation: B

Read more about these recommendations on topical antimicrobials and antiseptics 

Atopic individuals are predisposed to skin infections because of a compromised physical barrier, coupled with diminished immune recognition and impaired antimicrobial peptide production. Staphylococcus aureus, in particular, is a frequent culprit and colonizer of the skin in AD. Its presence, even without overt infection, appears to trigger multiple inflammatory cascades, via toxins that act as superantigens and exogenous protease inhibitors that further damage the epidermal barrier and potentiate allergen penetration.

A 2010 Cochrane review of RCTs found a lack of quality trials to support the use of antimicrobial and antiseptic preparations to treat AD (further discussed in part 3 of these guidelines).110 The review also did not find any clear benefit for topical antibiotics/ antiseptics, antibacterial soaps, or antibacterial bath additives in either the setting of clinical infection or uninfected AD, noting that even positive findings in studies often had poor reporting of details. Although the addition of a topical antibiotic to a topical steroid reduces the amount of Staphylococcus aureus iso- lated from the skin, the combination has not been found to improve either global outcomes or disease severity compared with the steroid alone.59,111,112 Thus, topical antimicrobial preparations are not generally recommended in the treatment of AD. They can be associated with contact dermatitis, and there is also concern that their use could promote wider antimicrobial drug resistance.

Navigate section 2 of the AD guideline: Topical therapy  

Citation note 

When referencing this guideline in a publication, please use the following citation: Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32.


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