eMedicine Specialties > Dermatology > Bacterial Infections

Impetigo: Follow-up

Author: Sadegh Amini, MD, Senior Clinical Research Fellow, Skin Research Group, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami
Coauthor(s): Anne E Burdick, MD, MPH, Professor of Dermatology, Director of Leprosy Program, Associate Dean for TeleHealth and Clinical Outreach, University of Miami Miller School of Medicine
Contributor Information and Disclosures

Updated: Sep 8, 2009

Follow-up

Further Inpatient Care

  • Impetigo typically resolves with topical or oral antibiotics; only rarely do serious complications occur. Vancomycin may be required for complicated methicillin-resistant Staphylococcus aureus (MRSA) infections that do not improve with standard oral antibiotics.

Further Outpatient Care

  • Schedule a follow-up visit within 1 week.
  • If the lesions have not improved, check the bacterial culture and sensitivity results, look for MRSA, and prescribe alternative antibiotics accordingly.
  • If the patient was treated with oral antibiotics, prescribe alternative antibiotics depending on bacterial culture and sensitivity results.

Deterrence/Prevention

  • Treat traumatized skin with mupirocin because this has been shown to decrease the rates of impetigo spread.
  • Evaluate hospital nursery staff and household members for pyodermas or asymptomatic bacterial carrier states.
  • Treat preexisting underlying skin diseases, such as atopic dermatitis. Antihistamines and topical steroids help decrease scratching. Treating the underlying disease has also been shown to decrease the pathogen count on the skin.
  • Teach good personal hygiene. For example, keep nails short and clean and wash hands frequently with antibacterial soap and water or waterless antibacterial cleansers.
  • For patients with recurrent impetigo, asymptomatic family members, and S aureus nasal carriers, prescribe 2% mupirocin cream or ointment (Bactroban) for application inside nostrils 3 times per day for 5 days each month to reduce colonization in the nose. Retapamulin may replace mupirocin for this indication, although data are needed to support its use in this setting.
  • Patients who are chronic nasal carriers can also be treated with clindamycin or rifampin plus dicloxacillin.
  • Advise patients about improving environmental conditions through the addition of air conditioning and by keeping surroundings clean.

Complications

Rarely, lesions resolve with scarring and postinflammatory hyperpigmentation or hypopigmentation.

  • Bullous impetigo
    • Cellulitis, lymphangitis, bacteremia with subsequent pneumonitis, septic arthritis, and septicemia may develop. This would require hospitalization with intravenous antibiotic therapy.
    • If the exfoliative toxins are absorbed into the bloodstream, staphylococcal scalded skin syndrome can result. This occurs more commonly in younger children, who have not developed antibodies against this toxin.
  • Nonbullous impetigo
    • Acute glomerulonephritis develops in 2-5% of individuals with impetigo due to S aureus and group A beta-hemolytic streptococci (GABHS), most often in children aged 2-4 years. The onset is usually 10 days after impetigo lesions first appear, but it can occur from 1-5 weeks later. Transient proteinuria and hematuria may occur during impetigo and resolve before renal involvement develops. Antibiotic treatment does not prevent the development of glomerulonephritis, but it limits the spread of the disease to other individuals.
    • Ecthyma, a deep dermal infection, can result, after which subsequent scarring can occur. Scarlet fever, erysipelas, cellulitis, lymphangitis, and, rarely, bacterial endocarditis may also develop.
    • Impetigo can complicate patients with chronic renal failure, particularly patients on dialysis and post–renal transplantation patients.
    • Less common complications include sepsis, arthritis, osteomyelitis, pneumonia, lymphadenitis, guttate psoriasis, toxic shock syndrome, and staphylococcal scalded skin syndrome.6,10

Prognosis

  • Spontaneous healing rarely occurs. If left untreated, some lesions may resolve spontaneously, while new lesions appear elsewhere on the body.
  • Resolution of lesions usually occurs after 7-10 days of treatment. If lesions have not resolved within 7-10 days of antibiotic therapy, cultures should be performed to look for resistant organisms.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to evaluate hospital nursery staff for active impetigo lesions or carrier states if indicated
  • Failure to check patient blood pressure for hypertension and urine for hematuria or proteinuria as a screen for poststreptococcal glomerulonephritis
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Ivan D. Camacho, MD, in the development and writing of this chapter.



More on Impetigo

Overview: Impetigo
Differential Diagnoses & Workup: Impetigo
Treatment & Medication: Impetigo
Follow-up: Impetigo
Multimedia: Impetigo
References
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Further Reading

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Keywords

impetigo, impetigo contagiosa, Fox impetigo, impetigo bullosa, impetigo contagiosa bullosa, impetigo neonatorum

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Contributor Information and Disclosures

Author

Sadegh Amini, MD, Senior Clinical Research Fellow, Skin Research Group, Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami
Sadegh Amini, MD is a member of the following medical societies: American Society for Dermatologic Surgery, International Society for Dermatologic Surgery, and International Society of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Anne E Burdick, MD, MPH, Professor of Dermatology, Director of Leprosy Program, Associate Dean for TeleHealth and Clinical Outreach, University of Miami Miller School of Medicine
Anne E Burdick, MD, MPH is a member of the following medical societies: Washington State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

James J Nordlund, MD, Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine
James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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