Recurrent skin infections

What are recurrent skin infections?

Honestly speaking, there isn’t really a proper definition for a “recurrent” skin infection.
Any time a new lesion appears while the child or a family member has started recovering from a previous episode of impetigo or from a skin abscess, the new lesion is referred to as a “recurrent’ skin infection. And if this happens to recur more than once, then it is certainly referred to as a recurrent infection.

What are the reasons behind recurrent skin infections?

The cause of recurrent infection could be related to the child’s environment or to the bacteria causing the infection.
Let’s start with environment. Since skin infections are transferred through contact between children or shared objects, the minute a child with active skin infection returns to kindergarten – he/she could transfer the infection to his/her friends who could transfer it to children who have just recovered from an infection themselves, thus producing a loop of recurrent infections.
This is how impetigo keeps recurring in a kindergarten for weeks at a time. It is important to ensure that kids with active lesions do not return to daycare/kindergarten until all their lesions have dried up and can be fully covered.
Children that get injured a lot or scratch on their insect bites tend to get all kind of skin infection more often, simply because they usually have more wounds on their skin. In such cases, it is important to take good care of the child, to clean and disinfect their wounds properly, to maintain good hand hygiene and to keep their nails short. If they happen to have very itchy bites, then anti-itch medicine such as Dimethindene maleate (Fenistil, Foristal) are helpful. These drugs can also have a sedating effect which could be useful if the child is irritable (and scratching all day long), you can read more about this here.
Children with atopic skin, i.e dry and wounded – such skin tends to get infected more frequently. In these children it is best to moisturize and treat their atopy so as to reduce the frequency of infections.

Recurrent infections can be due to immune deficiency – quite rare.

Now to the bacteria – usually in recurrent skin infections we’re talking about the carriage a large quantity of bacteria named Staphylococcus aureus, found most commonly in the nostrils and on facial skin. When the bacteria resides on different sites on the body, it’s easy for it to move from one spot to the other (child may pick on his nose and then touch something else for example). When the bacteria comes in contact with superficial wounds it settles there and causes infection.

How do you find out if your child is a carrier of Staphylococcus aureus?

You can swab the nostril and get it cultured. Yes, nasal swabs – just like COVID, we’re all pros by now….

In practice, if a child with recurrent skin infections tests negative on the nasal swab, sometimes their physician will still offer Staphylococcus aureus decolonizing treatment (more about this below). A positive swab will confirm the diagnosis and allow for an understanding of the sensitivity profile of the bacteria and hence the appropriate antibiotics.

At times, the child doesn’t only carry the “simple” bacteria but actually the more complex, resistant bacteria called Methicillin Resistant Staphylococcus Aureus, or MRSA. MRSA is resistant to the conventional antibiotics given for recurrent skin infections and so when MRSA infections are treated with the regular antibiotics, the infection doesn’t disappear completely but tends to recur. Unfortunately, the prevalence of this resistant bacteria in the general population is rising, mostly due to the overuse of antibiotics and its easy transmission amongst children.
Resistant bacteria are suspected when the skin infection does not improve despite conventional antibiotic treatment (such as Cephalexin).
Therefore, in such cases, and in children with recurrent infections, it is very important to make sure a swab is taken from the pus produced by the infection. The swab should be sent for culture – the results of the culture will help us learn more about the bacteria that caused the infection, whether it is resistant, and will allow us to select the appropriate antibiotic, according to sensitivity profiles of the bacteria.
It is, of-course, important to also remind ourselves that a different diagnosis could exist and that not all skin infections that seem to be bacterial are always caused by bacteria. A well experienced pediatrician will usually be able to recognize the type of infection presented.

What should be done in cases of recurrent skin infections?

I think we can summarize it into 3 simple steps:
1. See your doctor and get a proper diagnosis and treatment plan. Make a joint decision regarding the need for nasal or wound swab cultures (to check for carriage of staphylococcus aureus).
2. Try to identify any environmental factors that could be causing recurrent infections – check to see if the parents’ daycare group chat has mentioned anything about recurrent skin infections. Make sure not to send your child into daycare if he/she still has infectious lesions that cannot be fully covered. If your child has atopic dermatitis, see your doctor and consult with him regarding the optimal treatment for them. Furthermore, try to maintain good skin hygiene, keep your child’s nails short, disinfect their wounds and prevent them from itching (by providing medication if needed). Read more of atopic dermatitis here.
3. Identify children/family members who are carriers of Staphylococcus aureus bacteria (be it sensitive or resistant to the conventional treatment) and have them undergo “decolonizing” treatment. Read more about this below.

What is bacterial decolonization?

The presence of bacteria on skin or in the nostrils is referred to as ‘colonization’, from the term ‘to colonize’. That means the bacteria kind of resides or lives in these sites. Decolonization means removing the bacteria from such sites. By reducing the quantity of bacteria residing on the skin or nostrils one can prevent recurrent infections in oneself and his/her surroundings.

How can ‘decolonization’ be achieved?

1. With the use of antibiotic ointment designated for the inside of the nose, applied twice a day for 5 days.
2. With the help of an antiseptic soap, used daily for 5 days. This soap is to be applied to the skin and hair (the bacteria could reside on the scalp, as well). The soap should be allowed to sit on the scalp for one or two minutes so the job can be done. The use of a regular shampoo and conditioner after the antispectic soap is washed off is advised as the soap could cause dryness of the skin and hair. Repeat this for 5 days. If you want to really make sure you got everything you can continue using is once or twice a week for several weeks.
3. In some very resistant cases, we recommend swabbing all family members to find out if there is a family member who is the main source of all the recurrent infections.
4. The doctor may sometimes add an oral antibiotic for a more significant effect.

From my personal experience, decolonizing treatment (using one or all of the options mentioned above) does really work to reduce the number of recurrent skin infections.

To conclude, recurrent skin infections are very common in children and some children will suffer from annoying episodes that will require recurrent antibiotic courses, and that’s really a pity. These episodes could be related to the type of bacteria causing it and other times they will be affected by environmental factors. The good news is that there is treatment and possibly even a route of prevention, and it works!

All the best.