Disinfectant therapy to staphs on atopic skin and the topical steroid resistance (TSR)

I don’t know if the same kind of therapy exists in other countries than Japan. I have never found the similar therapy in other countries by the Pubmed (medical scientific article sauce, http://www.ncbi.nlm.nih.gov/pubmed).

The disinfectant therapy includes various methods.Theoretically there are as many methods as the number of disinfectants. Anyway, the disinfectant therapy means applying a certain disinfectant to the patient’s skin, waiting for a while (usually a few minutes) and washing the disinfectant away by shower. That is all.

Povidon-iodine and electrolyzed strong acid aqueous solution are both preferable disinfectants. Do you know the electrolyzed strong acid aqueous solution? It became popular in 90’s in Japan in the medical field. It is because the problem of MRSA (Methicillin-resistant Staphylococcus aureus) emerged at that time. The staphs could be sterilized by oral antibiotics more effectively than disinfectant but it would also increase the risk of emersion of MRSA. So various trials were done at that time in Japan and use of the electrolyzed strong acid aqueous solution in the medical field was one of them.

By search of Pubmed, I couldn’t find any article about the electrolyzed strong acid aqueous solution by non-Japanese researcher. So I am not sure if it is also used in the medical field in other countries. The solution is produced from the tap water, a bit of salt (NaCl) and a kind of electric device (Figure below).
The electrolyzed water around anode indicates low value in pH. The acid water below 2.7 in pH is the electrolyzed strong acid aqueous solution. It sterilizes every kind of bacteria nonspecifically.  The shortage is that the solution is unstable. So it is recommendable to purchase the device itself.  The device costs about JPN 50-100 thousand (USD about 500-1,000). The price differs by provider or the time to purchase. In fact, I have my own device in my clinic too. I sanitize environments around my operation room by that solution.

For atopic dermatitis, the below illustration will help you to comprehend the procedure. The illustration is from a brochure of a provider of the electrolyzed strong acid aqueous solution.

The solution doesn’t irritate the skin at all although its pH is very low. It is because the solution becomes just oxidized by the contact to the skin. It reduces the very superficial layer of the skin and bacteria to disinfect. The action is so instantaneous that it never damages the substantial skin. It is recommendable even for infants and children. And you don’t need to wash the solution away in several minutes like other disinfectants.

Povidone-iodine 10% solution is another disinfectant commonly used for the treatment of atopic dermatitis. It was first put forward in 1990 by Sugimoto, a pediatrician in Japan. He has written several medical articles about the method.

New successful treatment with disinfectant for atopic dermatitis. Dermatology 1997; 195(suppl 2):62–68.

The Importance of Bacterial Superantigens Produced by Staphylococcus aureus in the Treatment of Atopic Dermatitis Using Povidone-Iodine. Dermatology 2006;212(suppl 1):26–34

The photos below is the procedure.

First the patient applies povidone-iodine 10% solution directly to the skin. Note that there are many povidone-iodine liquid products. Some of them contains alcohol (for gargle) or detergents (for hand wash) and are not suitable for this therapy. Only 10 % simple aqueous solution can be used.

After 2-3 minutes the patient washes the disinfectant away completely by shower. The patient then applies emollients like simple white petrolatum. That is all.

Comparing the above two disinfectants, the strength as a disinfectant is maybe larger in povidone-iodine. But the stimulus is also more in povidone-iodine. Moreover, the povidone-iodine has the risk of sensitization while the electrolyzed strong acid aqueous solution does not. So I recommend the electrolyzed strong acid aqueous solution for patients who are not under skillful dermatologists.

The biggest problem of staphs on atopic skin is that it can cause the topical steroid resistance (TSR). Staphs produce a kind of toxins and they effect as superantigens which accelerate immune reaction nonspecifically. The patient who suffers from TSR develops ineffectiveness to topical steroids. The patient present very similar skin symptom to TSA and sometimes TSR is accompanied with TSA.

Here is a case with TSR and TSA. His eczema relapsed at the age of 18 after long remission period from infancy. The amount of TS prescribed in the former dermatologist for 5 years before the first visit to me is as follows.

Amount of TS (gram per year)

The patient reacted to TS at first but became to feel ineffectiveness since 27 years old. So the patient discontinued. The patient was introduced by the former dermatologist to me because of difficulties in treatment. The appearance of the patient at first visit was as the below photo.

How do you think his skin manifestation? It is so-called erythroderma but the point is that his skin manifestation consisted of very few elements. That is, the element was almost erythema only. In such a case, the TSA is not so severe. If he had various elements, especially prurigo, I judge his TSA is severer.

There are two possibilities of his ineffectiveness to TS; TSA and TSR.
You may say there is a possibility of contact dermatitis to TS or emollient etc. But the patient came to me after four months’ discontinuance of TS and he had never applied anything to the skin for that period. If he suffered from contact dermatitis to something, He must have recovered at that time. So contact dermatitis is excluded.

I examined the staphs on the skin by culture. There were enormous number of staphs. So I recommended the disinfectant therapy using povidone-iodine. Staphs cause TSR and worsen the dermatitis itself. Such patients may develop steroid-resistant dermatitis.

The above photo is one month after the first visit.

The above is three months after the first visit.

 The above is 6 months after the first visit.

 8 months
 10 months
1 year

1 year and three months after the first visit. He had never used any medication except for disinfectant and white petrolatum. So it is his original skin. The eruption seen at the first visit was TSR accompanied with TSA and was not of his original eczema.
The below is a flow chart summary for the better understanding.
Be smart and wise enough not to fail to recognize your own situations. Because only you can know the whole procedure of eczema and judge correctly.

Sorry, the comment column is not available now. But the author believes readers can find some hints to overcome their own situations by the previous comments.

21 件のコメント:

  1. Hi Dr Fukaya, I want to tell you how much I like and appreciate your blog. You explain what is happening well, and make sense of this horrible process.

    Although I find some of the science a little hard to understand, I know enough to grasp the concept. I have been suffering from TSW since January 2011, and quickly thought there must be some change to receptors in the epithelial cells(I didn't think if lymphocytes!). To me, this explains why the healing process takes so long - the cells have to revert to pre-steroid physiology. I certainly think there is a immune element to the withdrawal process too.

    I definitely find that staph on my skin effects me. It makes areas that are dry and sore much worse. I try to control it with daily Dead Sea salt baths and antibiotic cream (Fucidin) When my skin was very bad, I occasionally tried diluted bleach baths - a recognised treatment for eczema here in the UK. It is particularly popular with treating children. The process involves washing in a weak bleach solution, and then washing off thoroughly. I found it too harsh for full body baths, but instead soaked my worst areas (arms and neck) for 5 minutes in the solution followed by my usual bath. It definitely made the skin less angry, although I don't think my skin would have been able to tolerate it in the earlier stages if TSW.

    Thank you again, and please contact me if you want to. Natalie Allcock

    1. Thank you for the comment. Judging from your phrases, you native speakers of English seem to be able to understand the contents of my blog. I will continue to write more.
      I was really afraid of misunderstanding because the information I’d like to transmit is so complicated and technical for my English ability.

  2. Your flow chart is so helpful! I am able to understand everything on your blog - I've read every post so far. Although there are some technicalities, your English is good enough for me to understand it! (I guess it helps that I am in biomedical research as well) The last flow chart was so helpful as well since I don't know who to go to if I want to get a diagnosis. I have sent Dr. Rapaport an email, but I have a feeling his practice is too expensive for a poor college student like me.

    Thank you so much for your blog. It is amazing! What do you suggest we do if we cannot get disinfectants that you talked about? I am starting to suspect that I have TSA since I have been using steroids on and off since infancy, but since only ~20% are affected by it I don't know what to think. What I do know is that it seems only way I can keep flare ups away are if I use steroids, every day. I haven't used it for about a week or two, then i got weepy scalp and face and lots of patches everywhere on my body, then used the steroids everywhere and it went away in few days. However, since I stopped when I got better, it took two day before I started to get signs of flare ups again.

    Anyways, please keep posting. Thank you so much!

    1. Maybe you are not addicted yet because steroids are still effective to you by a few days’ application. But it doesn’t mean steroids work forever from now on. I recommend you should try various methods while temporarily suppressing your eczema by topical steroids. Disinfectant therapy is one of them. I think Povidone-iodine solution is a very common medical item and you could find it in your country also. Please consult with a pharmacist in the neighborhood. Thank you for your comment and information that you can understand my English. We Japanese are one nation and one language people and most of us are not used to communicate in other language.

    2. Thank you so much for replying! I am worried about the steroid cream mainly because while it takes away my back cuts, there are spots in my arm that will not go away. Also when I stopped steroid for couple days, my eyes swelled up a lot and that hasn't happened since three years ago. Also the places eczema patches are occurring are now not anywhere it used to occur when I was younger. I worried that I will get more addicted. Will HA solution help with that? How do I use it exactly? Do I put it on places I would put steroid creams on?

    3. I can’t diagnose only from your description but you might have already dropped to addiction.
      Sorry for my double answers. Anyway my hyaluronic acid lotion should help your situation. It can weaken the side effects of steroids. If I were you, I would definitely apply hyaluronic lotion also to the area where I apply topical steroids.

    4. Thank you so much for your fast reply! I will definitely buy some soon. You are awesome for answering questions! It's a confusing and lonely disease, this tsa, your guidance is very appreciated!

  3. Hi, if using 10% povidone Iodine treament, how often do I need to use it and what does sensitization mean?

    1. Dr. Sugimoto who proposed this therapy recommends 1-4 times a day. Sensitization is the formation of allergic contact dermatitis.

  4. You are very good at explaining the complex information. Thank you so much for all the time, effort, knowledge, and love you share with all TSW sufferers around the world like my 10 year old son. Make no mistake, Dr. Fukaya, there is a GOD, and he is working through you! God bless you!

  5. Hi I want to thank you for this blog, it really helped me through my TSW. I was lucky, my TSW lasted only 3 months while I have used steroids for more than 20 years.
    I felt that taking supplements really helped. Now that I recovered, I still have a problem with staph. I had taken the antibiotic Batrim for 2 months, as soon as I stopped, within a few days I got itches and later on spots of rash. I have to go back on Batrim. Doctor wants me to do chlorine bath but that is too harsh so I bought an electrolyzed water machine here in the US. My question is how safe is the electrolyzed strong acid aqueous solution? Can I dip my whole hand or body parts into the strong acid aqueous solution? or can I only spray it on as recommended? Thats for you blog and your help.

    1. >Can I dip my whole hand or body parts into the strong acid aqueous solution?
      Yes. The PH of the solution is very low but it does no harm to the skin. I am happy to know you are doing well.

    2. Thanks for the reply. So for skin purpose, we can use 2.7ph acid water or even lower correct?

  6. Sir,
    1. The above patient was resistant to steroids and you deduced this due to taking culture?
    2. Also I have questions regarding tsa. If the steroid is still working patient will not be in tsa? I am referring to your answer to n log question.
    3. If contact dermatitis is in fact the issue would tsa occur. I am not understanding that process. If a patient has contact dermatitis will they fall into tsa?
    4. What is your differential Dx for tsa. I have learned so far. Contact allergy. Staph infection.
    5. Have you posted on your blog on the stages of tsw?
    Sorry for all these questions.

    1. 1.I took culture of staph in all patients at that time. The patient had countless staphs on the skin.
      2.Even if topical steroids work in a patient, TSA can’t be excluded from diagnosis. It is sorry to say but the true diagnosis can be obtained retrospectively only after the patient has withdrawn. We can only suspect TSA by signs before withdrawal.
      3.Contact dermatitis can become the initiation of TSA if the cause is not found or eliminated. Hand eczema is an example.
      4. The biggest Dx is the original skin disease itself, e.g. atopic dermatitis, contact dermatitis etc.
      5.Please refer to the article and fond the description.

  7. Hello Dr Fukaya,

    Could staph on the skin be the reason why I experience prickly and itchy sensation every time I start to sweat?

    Also, if I do not have access to the machine mentioned in your post and Povidone-iodine 10% solution irritates my skin, are there any other alternative treatments (i.e. anti bacterial soap)?

    (Sorry if this is a double post not sure if the first one went through).


    1. You can confirm if staph is really an aggravating factor in your case by taking oral antibiotics. Short term use of oral antibiotics will not induce resistance.

    2. Hi Dr Fukaya,

      I am just about to finish a course of cephalexin and can confirm that I am still feeling the prickly sensation so it is safe to say that staph is not causing this.

      Is this common in the TSW patients that you have encountered??

      It has been two years already since I have started TSW and have even not used any moisturiser for most of the two years but I still feel so prickly and itchy when I sweat even a little bit!


  8. Hello, I'm living in Japan and I'm wondering where to get the staph treatment. Thank you

    1. Povidone-iodine therapy was originated by Dr. Kazuo Sugimoto (Chiba city Aoba hospital). But I feel this therapy can be tried by patients themselves without instruction by doctors.


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