eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Impetigo: Treatment & Medication

Author: John Ratz, MD, MBA, Staff Dermatologist, Mohs Surgeon, Center for Dermatology and Skin Surgery, Inc
Coauthor(s): Daniel B Ward Jr, MD, Clinical Assistant Professor, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Nov 5, 2009

Treatment

Medical Care

Medical management may involve topical therapy alone or a combination of systemic and topical therapies.

  • Topical therapy
    • First, remove the infected crusts and debris with soap and water. If the infection is mild and localized, topical mupirocin alone may be the only necessary therapy. Studies indicate this topical antibiotic, although expensive, is as effective as oral erythromycin for treating impetigo. Furthermore, the cost difference between these two treatments may be offset by the increased incidence of adverse effects associated with erythromycin.
    • Disadvantages of topical treatment are that it cannot eradicate organisms from the respiratory tract and applying topical medications to extensive lesions is difficult.
    • No studies indicate that other topical antibiotics are as effective as systemic therapy.
  • Systemic therapy
    • When infection is moderate to severe or accompanied by lymphadenopathy, systemic therapy is indicated.
    • The drug preferred for impetigo caused by S pyogenes is penicillin. Substitute clindamycin in patients who are allergic to penicillin.
    • In cases caused by S aureus, clindamycin or cephalexin may be used.
    • Treat erythromycin-resistant S aureus impetigo with a cephalosporin (eg, cephalexin, clindamycin).

Medication

The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Penicillin V (Penicillin VK, Veetids)

Interferes with cell wall mucopeptide synthesis during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Not recommended for staphylococcal impetigo.

Adult

500 mg PO q6h

Pediatric

<50 lb: 500 mg/d PO divided qid for 10 d
>50 lb: Administer as in adults

Probenecid can increase effects; coadministration of tetracyclines can decrease effects

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function


Cephalexin (Keflex)

Recommended for impetigo caused by S aureus resistant to erythromycin. First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora. Used for skin infections or prophylaxis in minor procedures.

Adult

500 mg PO q6h for 10 d

Pediatric

25-50 mg/kg/d PO q6h for 10 d; not to exceed 3 g qd

Coadministration with aminoglycosides increases nephrotoxic potential

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment


Amoxicillin clavulanate (Augmentin)

Indicated for skin and skin structure infections caused by beta-lactamase–producing strains of S aureus that are resistant to erythromycin.
Administration with food may decrease GI adverse effects.

Adult

500 mg of amoxicillin with 125 mg of clavulanate PO tid for 7-10 d

Pediatric

Children > 3 months: Base dosing protocol on amoxicillin content; due to different amoxicillin-to-clavulanic acid ratios in 250-mg tab (250:125) vs 250-mg chewable tab (250:62.5), do not use 250-mg tab until child weighs >40 kg
<40 kg: 6.7-13.3 mg/kg of amoxicillin and 1.7-3.3 mg/kg of clavulanate PO tid for 7-10 d
>40 kg: Administer as in adults

Administer at least 1 h apart from aminoglycosides to prevent mutual inactivation; coadministration with warfarin or heparin increases risk of bleeding

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Prescribe for a minimum of 10 d to eliminate organism and prevent sequelae (eg, endocarditis, rheumatic fever); following treatment, perform culture to confirm streptococci eradication


Clindamycin (Cleocin)

Alternative therapy for S aureus resistant to erythromycin. Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Adult

300 PO q8h for 10 d

Pediatric

Administer as in adults

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin and chloramphenicol may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Possible cross-sensitivity between clindamycin and doxorubicin; adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis


Retapamulin (Altabax)

Topical antibiotic available as a 1% ointment. First of new antibiotic class called pleuromutilins. Inhibits protein synthesis by binding to 50S subunit on ribosome. Indicated for impetigo caused by S aureus or S pyogenes.

Adult

Apply topically to affected site bid for 5 d

Pediatric

<9 months: Not established
>9 months: Apply as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause irritation at application site (1.4%); avoid application to eye area; keep out of reach of children

More on Impetigo

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

  1. Ludlam H, Cookson B. Scrum kidney: epidemic pyoderma caused by a nephritogenic Streptococcus pyogenes in a rugby team. Lancet. Aug 9 1986;2(8502):331-3. [Medline].

  2. Cunha BA. Antibiotic Essentials. Royal Oak, Mich: Physicians Press:2005.

  3. Dajani AS, Ferrieri P, Wannamaker L. Endemic superficial pyoderma in children. Arch Dermatol. Oct 1973;108(4):517-22. [Medline].

  4. Dajani AS, Ferrieri P, Wannamaker LW. Natural history of impetigo. II. Etiologic agents and bacterial interactions. J Clin Invest. Nov 1972;51(11):2863-71. [Medline].

  5. Dillon HC Jr. Topical and systemic therapy for pyodermas. Int J Dermatol. Oct 1980;DA - 19810424(8):443-51. [Medline].

  6. Drug Information for the Health Care Professional. USP DI-Volume I. 17th ed. Chicago, Ill: Rand McNally; 1997.

  7. el Tayeb SH, Nasr EM, Sattallah AS. Streptococcal impetigo and acute glomerulonephritis in children in Cairo. Br J Dermatol. Jan 1978;98(1):53-62. [Medline].

  8. Elias PM, Levy SW. Bullous impetigo. Occurrence of localized scalded skin syndrome in an adult. Arch Dermatol. Jun 1976;112(6):856-8. [Medline].

  9. Ferrieri P, Dajani AS, Wannamaker LW, et al. Natural history of impetigo. I. Site sequence of acquisition and familial patterns of spread of cutaneous streptococci. J Clin Invest. Nov 1972;51(11):2851-62. [Medline].

  10. Ginsburg CM. Staphylococcal toxin syndromes. Pediatr Infect Dis J. Apr 1991;10(4):319-21. [Medline].

  11. Hay RJ, Adriaans BM. Bacterial Infections. In: Champion RH, Breathnach SM, Burns AD, et al, eds. Textbook of Dermatology. 6th ed. Oxford, England: Blackwell Science; 1998:1097-1179.

  12. Hirschmann JV. Bacterial infections of the skin. In: Sams WM Jr, Lynch PJ, eds. Principles and Practice of Dermatology. 2nd ed. New York, NY: Churchill Livingstone; 1993:79-88.

  13. Hirschmann JV. Topical antibiotics in dermatology. Arch Dermatol. Nov 1988;124(11):1691-700. [Medline].

  14. Kahn RM, Goldstein EJ. Common bacterial skin infections. Diagnostic clues and therapeutic options. Postgrad Med. May 1 1993;93(6):175-82. [Medline].

  15. Lee PK, Weinberg AN, Swartz MN, et al. Pyodermas: Staphylococcus aureus, Streptococcus, and Other Gram-Positive Bacteria. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al, eds. Dermatology in General Medicine. 4th ed. New York, NY: McGraw-Hill; 1999:2182-2207.

  16. Mertz PM, Marshall DA, Eaglstein WH, et al. Topical mupirocin treatment of impetigo is equal to oral erythromycin therapy. Arch Dermatol. Aug 1989;125(8):1069-73. [Medline].

  17. Rice TD, Duggan AK, DeAngelis C. Cost-effectiveness of erythromycin versus mupirocin for the treatment of impetigo in children. Pediatrics. Feb 1992;89(2):210-4. [Medline].

  18. Scales JW, Fleischer AB Jr, Krowchuk DP. Bullous impetigo. Arch Pediatr Adolesc Med. Nov 1997;151(11):1168-9. [Medline].

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Further Reading

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Keywords

impetigo, skin infection, cutaneous infection, bullous impetigo, nonbullous impetigo, Staphylococcus aureus, S aureus, Streptococcus pyogenes, S pyogenes, group A Streptococcus, GAS, group A streptococci, streptococci, staphylococci

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Contributor Information and Disclosures

Author

John Ratz, MD, MBA, Staff Dermatologist, Mohs Surgeon, Center for Dermatology and Skin Surgery, Inc
John Ratz, MD, MBA is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physicians, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, International Society for Dermatologic Surgery, and Southern Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Daniel B Ward Jr, MD, Clinical Assistant Professor, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina
Daniel B Ward Jr, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Gregory William Rutecki, MD, Associate Professor, Program Director, Department of Internal Medicine, Feinberg School of Medicine, Northwestern University
Gregory William Rutecki, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Nephrology, National Kidney Foundation, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gordon L Woods, MD, Consulting Staff, Department of Internal Medicine, University Medical Center
Gordon L Woods, MD is a member of the following medical societies: Society of General Internal Medicine
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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