TABLE 1.

Theoretical advantages and disadvantages of topical antimicrobial therapy for bacterial skin infections

Advantage/disadvantage
Advantages
May enable targeted delivery of a high concentration of antimicrobial to site of infection
Higher likelihood of adherence to treatment (e.g., in children)
Less potential for systemic side effects and toxicity
May avoid need for systemic antimicrobials
Ensures that site of infection is regularly inspected
Topical application allows use and development of agents that may not be able to be used systemically (e.g., neomycin or bacitracin)
Topical route of administration may be easier for patients and caregivers
Disadvantages
Limited evidence base for clinical effectiveness
Many agents associated with local allergy
Limited understanding of potentially deleterious effects on skin microbiota
Minimal depth of penetration, limiting use on intact skin
Unquantified effects on wound healing process
Widespread and unrestricted use is likely to select for bacterial resistance (e.g., fusidic acid and Staphylococcus aureus)
Potential for storage in patient homes, with possibility of recurrent use and contamination
Often combined with topical steroid therapy, meaning that primary prescribing indication may be for inflammation rather than infection
Potential perception by both patients and prescribers as more “benign” than systemic antimicrobials
May be difficult for some patients to apply to larger surface areas or skin folds