Antibiotic Cream and Moisturiser for Infected Eczema: Which Goes First, and How Long to Wait?

Infected eczema is one of the most common reasons a child with eczema ends up at the GP, and the appointment usually ends with a tube of antibiotic cream, most often fusidic acid (Fucidin), and the instruction to carry on with the emollient. What the appointment rarely covers is the practical bit: which cream goes on first, how long to leave between them, and what to do about the moisturiser on the infected patch.

Here is how I explain it in clinic.

The Short Answer

Apply the antibiotic cream first, thinly, to the infected patch only, exactly as prescribed. Wait 20 to 30 minutes, then apply your moisturiser as normal. That is the gap the NHS suggests between a treatment cream and an emollient, and it stops the moisturiser diluting the antibiotic or spreading it onto skin that doesn't need it. Keep moisturising the rest of the skin as usual throughout the course. If your GP or pharmacist has given you a different order, follow theirs.

Why the Gap Matters

• Dilution. Moisturiser rubbed straight over a thin layer of antibiotic cream mixes with it, so less reaches the skin that needs it.
• Spread. Antibiotic cream is for the infected patch. Emollient on top carries it onto skin that isn't infected, which wastes it and, over time, encourages resistant bacteria.
• Absorption. Twenty to thirty minutes gives the treatment time to sink in before anything else goes on.

Step by Step

1. Wash your hands. The NHS advice is to wash before and after applying fusidic acid, unless you're treating your own hands.
2. Apply a thin layer of the antibiotic cream to the infected area only and rub it in gently. Keep it away from the eyes if the patch is on the face.
3. Wash your hands again, then wait 20 to 30 minutes.
4. Moisturise. Apply emollient generously to the rest of the skin, and over the treated patch too unless you've been told not to.
5. Repeat as prescribed. Fusidic acid cream or ointment is usually used three or four times a day; a combined cream with a steroid, such as Fucidin H, is usually twice a day. The course is typically about a week, sometimes two. Finish it even if the skin looks better sooner, so the infection doesn't come back.

How Do I Know the Eczema Is Infected?

The NHS lists these signs. Ask for an urgent GP appointment or get help from NHS 111 if your child's eczema:

• is blistered, crusty, leaking fluid or has spots filled with pus
• is painful, swollen or feels warm
• suddenly gets worse or gets bigger
• or your child has a high temperature or seems generally unwell

Golden-yellow crusting is the typical look of a bacterial infection. Groups of small fluid-filled blisters that break open into shallow sores, especially with a temperature, can be eczema herpeticum, a viral infection that needs treatment quickly. Don't wait and see with that one.

It's also worth knowing that not every flare is infected. NICE guidance points out that eczema flares are often not caused by bacterial infection, that antibiotics won't help those flares, and that antibiotics aren't routinely needed unless there are clear signs of infection. A flare that is simply red, dry and itchy usually needs more emollient and, if prescribed, a steroid cream, not an antibiotic.

What Your GP Might Prescribe

• A topical antibiotic for a small, localised patch. Fusidic acid 2% cream or ointment is the usual UK choice. NICE suggests three times a day for five to seven days; the NHS says courses are usually one to two weeks. Follow your prescription.
• An oral antibiotic, usually flucloxacillin, if the infection is widespread or your child is unwell.
• A combined cream such as Fucidin H (fusidic acid with hydrocortisone) or Fucibet (fusidic acid with betamethasone), which treats the infection and the inflammation together, for short courses only.

If the skin is no better after seven days of treatment, go back to your GP. If infections keep returning, your GP may take a swab to see which bacteria are involved.

Don't Keep Antibiotic Cream for the Next Flare

Leftover tubes are tempting. Please don't use them on every red patch. Repeated or prolonged courses of fusidic acid encourage resistant bacteria, which is why it's prescribed for a few days at a time. If you think the eczema is infected again, get it checked rather than reaching for the old tube.

Check the Cream Pot

Open tubs of emollient and steroid cream can become contaminated with bacteria, especially when fingers go in and out several times a day, and a contaminated pot can reinfect the skin. NICE guidance on eczema in children advises getting new supplies of your creams once an infection has been treated. In the meantime, take cream from a tub with a clean spoon or spatula, or choose a pump.

Keep Moisturising

An infection is not a reason to stop emollient. The rest of the skin still needs it at least twice a day, and once the antibiotic has absorbed, the treated patch usually does too. If a patch is weeping, a cream is easier to use than a greasy ointment; your GP or pharmacist can advise. One safety note: creams and ointments that dry onto clothes and bedding can make them catch fire more easily, whether or not they contain paraffin, so keep away from naked flames and wash bedding regularly.

When to See Your GP

• Any of the signs of infection listed above
• No improvement after seven days of antibiotic treatment
• Infections that keep coming back
• Your baby is under 3 months old and has a temperature of 38C or higher: call 111
• A rash that does not fade when you press a glass against it: call 999

For prescribed steroid creams, see Steroid Cream or Moisturiser First?, and for antifungal creams, Antifungal Cream and Moisturiser: Which Goes First?. For choosing a daily emollient, see our baby eczema cream range and Best Cream for Baby Eczema UK.

About Ovée

The Ovée Baby & Child Moisturising Cream and Dermatologist Lipid Cream are fragrance-free, paraffin-free, steroid-free everyday moisturisers that can be used alongside a treatment cream from your GP. Apply the treatment first, give it 20 to 30 minutes, then moisturise. Both come in airless pump bottles, so fingers never go into the cream. Neither is an antibiotic, and neither treats an infection.

Sources

• Fusidic acid, NHS. How and when to use it, course length, side effects, and when to go back to your doctor.
• Atopic eczema: symptoms, NHS. The signs of infected eczema and eczema herpeticum, and when to get urgent help.
• Secondary bacterial infection of eczema and other common skin conditions: antimicrobial prescribing (NG190), NICE, 2021. When antibiotics are and are not needed, and the recommended topical and oral choices.
• Atopic eczema in under 12s: diagnosis and management (CG57), NICE. New supplies of topical products after infected eczema has been treated.

Dr. Tim Clayton is a Consultant Paediatric Dermatologist, President of the British Society for Paediatric and Adolescent Dermatology, and Co-Founder of Ovée Skin Health.