Impetigo Treatment & Management

  • Author: Lisa S Lewis, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Oct 27, 2011
 

Approach Considerations

Treatment of impetigo typically involves local wound care along with antibiotic therapy. Antibiotic therapy for impetigo may be with a topical agent alone or a combination of systemic and topical agents.

Gentle cleansing, removal of the honey-colored crusts of nonbullous impetigo using antibacterial soap and a washcloth, and frequent application of wet dressings to areas affected by lesions are recommended. Good hygiene with antibacterial washes, such as chlorhexidine, may prevent the transmission of impetigo and prevent recurrences, but the efficacy of this has not been proven.

For antibiotic therapy, the chosen agent must provide coverage against both Staphylococcus aureus and Streptococcus pyogenes. Community-acquired methicillin-resistant S aureus (MRSA) infection most commonly manifests as folliculitis or abscess, rather than impetigo; thus, beta-lactam drugs remain an appropriate initial empiric choice.

Topical mupirocin is adequate treatment for single lesions of nonbullous impetigo or small areas of involvement. It is applied to the affected area 2 to 3 times daily. A 7-day course is usually standard, although few large studies have been performed to verify this as the most effective approach. Systemic antibiotics are indicated for extensive involvement or for bullous impetigo.

In patients with bullous impetigo who present to the emergency department with large areas of involvement resulting in denuded skin from ruptured bullae, management also includes intravenous fluid resuscitation. Fluid is given at a volume and rate similar to standard volume replacement for burns.

Inpatient care is required for patients with impetigo who have widespread disease or for infants at risk of sepsis and/or dehydration due to skin loss. If inpatient care is warranted in the child with untreated impetigo, contact isolation is recommended.

A clinical guideline summary from the Infectious Diseases Society of America that includes recommendations on impetigo, Practice guidelines for the diagnosis and management of skin and soft-tissue infections, may be helpful.[20]

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Topical Antibiotic Treatment

Topical antibiotic therapy is considered the treatment of choice for individuals with uncomplicated localized impetigo. Topical therapy eradicates isolated disease and limits the individual-to-individual spread. The topical agent is applied after removal of the infected crusts and debris with soap and water. Disadvantages of topical treatment are that it cannot eradicate organisms from the respiratory tract and that applying topical medications to extensive lesions is difficult.

Mupirocin

Mupirocin ointment (Bactroban) has been used for both the lesions and to clear chronic nasal carriers. Although it is expensive, it has been shown to be superior to topical polymyxin B and neomycin[32, 33] and to be equally effective as oral cephalexin. Both mupirocin and oral cephalexin are superior to bacitracin.[34] Unfortunately, S aureus and MRSA resistance to mupirocin has emerged at estimated rates ranging from 5-10%.[32, 35]

Retapamulin

Retapamulin (Altabax) ointment is in a new class of topical antimicrobials. It is approved by the US Food and Drug Administration (FDA) for treatment of localized impetigo caused by S pyogenes and methicillin-susceptible S aureus in children older than 9 months.[36, 37] It is applied twice daily for 5 days. It is not for mucosal use; epistaxis has been reported with nasal mucosa application.

Retapamulin has an excellent spectrum of activity, surpassing the bacterial spectrum of mupirocin.[32, 38] It has been shown to preserve its activity against bacteria that were resistant to multiple antibiotic drugs, such as methicillin, erythromycin, fusidic acid, mupirocin, azithromycin, and levofloxacin.[39, 40] The spectrum of retapamulin also includes erythromycin-resistant S pyogenes, fusidic acid–resistant and mupirocin-resistant S aureus, and MRSA (including P-VL–positive strains).[10]

In more than 1900 patients evaluated in several comparative studies, retapamulin has been demonstrated to be as effective as topical fusidic acid and oral cephalexin, with a low rate of adverse events.[32] In another study, retapamulin 1% ointment showed more efficacy than fusidic acid 2% ointment for the treatment of impetigo.[41]

Fusidic acid

Topical sodium fusidate (fusidic acid), currently not available in the United States, has been recognized as first-line therapy in Europe and other parts of the world.[6, 42] High resistance rates have been reported with the use of fusidic acid, however, ranging from 32.5-50%.[6, 41, 43, 44, 45]

A Swedish study of 38 patients with impetigo showed resistance of S aureus to fusidic acid in 75% of bullous cases and 32% of nonbullous ones. The authors recommended restricted use of fusidic acid in order to limit the rising levels of resistance.[46]

Other topical antibiotics

Other topical antibiotics have been reported to have some benefit for the treatment of impetigo. Clindamycin (cream, lotion, and foam) is useful in several MRSA infections.[47, 48] Gentamicin ointment or cream has been used in many countries for some gram-positive staphylococcal infections, including impetigo and pyoderma. Its use is precluded by the potential development of ear and kidney toxicity.[32, 47]

Hydrogen peroxide 1% cream, available in many countries, has demonstrated comparable bactericidal activity and longer duration of action than hydrogen peroxide 1% aqueous solution in vitro. It is applied 2-3 times a day on the affected area for a maximum of 3 weeks. Although the potential for sensitization is low, hypersensitivity reactions have been reported to other ingredients in the commercially available product.[47, 49]

Tetracycline has been used for localized impetigo. It is not widely prescribed because of the potential risk of skin photosensitivity reactions[5, 47] and because it is contraindicated in children younger than 8 years.

Drugs such as sulfanilamide, nitrofurazone, and silver sulfadiazine, which are widely used for the treatment of burns, are not currently used for the treatment of impetigo. Because of their antibacterial spectrum and proven efficacy and tolerability, these drugs may need to be considered in the future for the treatment of impetigo and other community-acquired skin infections.[32, 47]

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Systemic Antibiotic Treatment

Infections that are widespread, complicated, or are associated with systemic manifestations are usually treated with antibiotics that have gram-positive bacterial coverage. Systemic therapy is also recommended if multiple incidents of pyoderma occur within daycare, family, or athletic team settings.

Beta-lactamase resistant antibiotics (eg, cephalosporins, amoxicillin-clavulanate, cloxacillin, dicloxacillin) are recommended. Cephalexin appears to be the drug of choice for oral antimicrobial therapy in children.

Community-acquired MRSA has become widespread.[50] If MRSA is suspected, alternative antibiotics include clindamycin, trimethoprim-sulfamethoxazole, and vancomycin. Empiric treatment depends on the prevalence and sensitivities of MRSA in a particular geographic region.[51]

Erythromycin and clindamycin are alternatives in patients with penicillin hypersensitivity. Macrolide resistance has been increasing in the United States. Thus, avoid treatment of impetigo with erythromycin in geographic regions that are known to have a high resistance rate. Group A beta hemolytic streptococci (GABHS) and S aureus resistance to clindamycin has also been reported.

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Deterrence and Prevention

Children with impetigo should avoid close contact with other children if possible. Current recommendations call for the exclusion of children with impetigo from school or day care for 24 hours after the initiation of antibiotics.

Inspect household members for impetiginous lesions. With neonatal impetigo, also evaluate hospital nursery staff and household members for pyodermas or asymptomatic bacterial carrier states. Failure to treat other infected persons may result in continued transmission.

Treat traumatized skin with mupirocin because this has been shown to decrease the rates of impetigo spread. 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. Advise patients about improving environmental conditions through the addition of air conditioning and by keeping surroundings clean.

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.

Polymerase chain reaction to detect the mecA gene has become an effective tool for the screening for MRSA colonization upon hospital admission. However, screening has not been shown to significantly reduce transmission of and infection with MRSA.[10]

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Consultations and Long-Term Monitoring

The need for consultation is determined by the extent of involvement and the age of the patient. Neonates with bullous impetigo may require a consultation with a neonatologist.

Recurrent disease should trigger a specialist consult. Consult a nephrologist if signs and symptoms of acute glomerulonephritis develop.

Follow-up is important to ensure complete clearing of lesions. 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.

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Contributor Information and Disclosures
Author

Lisa S Lewis, MD  Consulting Staff, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center

Lisa S Lewis, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Allan D Friedman, MD, MPH  Chairman, Division of General Pediatrics, VCUH Health System; Professor of Pediatrics, Virginia Commonwealth University School of Medicine

Allan D Friedman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

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.

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: Women's Dermatologic Society

Disclosure: Nothing to disclose.

Ivan D Camacho, MD, Assistant Professor of Clinical Dermatology, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine; Medical Director of Dermatology Clinic, Jackson Memorial

Ivan D Camacho, MD is amember of American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Florida Medical Association, International Society of Dermatology, and the Women's Dermatologic Society.

Disclosure: Nothing to disclose.

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.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Glenn J Fennelly, MD, MPH Director, Division of Pediatric Infectious Diseases, Jacobi Medical Center; Associate Professor, Department of Pediatrics, Albert Einstein College of Medicine

Glenn J Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Eric M Kardon, MD, FACEP Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

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.

Andrew C Miller, MD Fellow, Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center; Attending Physician, Department of Emergency Medicine, University of Pittsburgh Medical Center

Andrew C Miller, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Rashid M Rashid, MD, PhD Resident Physician, Department of Dermatology, University of Texas, Houston, MD Anderson Cancer Center, and Morzak Research Initiative

Rashid M Rashid, MD, PhD is a member of the following medical societies: American Academy of Dermatology, Council for Nail Disorders, Houston Dermatological Society, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

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.

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.

Mark A Silverberg, MD, FACEP, MMB Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn

Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

Eric L Weiss, MD, DTM&H Director of Stanford Travel Medicine, Medical Director of Stanford Lifeflight, Assistant Professor, Departments of Emergency Medicine and Infectious Diseases, Stanford University School of Medicine

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

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Nonbullous impetigo with vesicles, pustules, and sharply demarcated regions of honey-colored crusts.
Bullous impetigo with circumscribed lesions with a thin collarette of scale.
Bullous impetigo on the buttocks. Courtesy of Medical University of South Carolina, Department of Dermatology.
Following dermabrasion, this patient developed nonbullous impetigo in the same area as several herpes simplex lesions.
A nummular eczema lesion on the knee, impetiginized with Staphylococcus aureus.
Nonbullous (crusted) impetigo resulting from a chigger bite infected by group A beta-hemolytic streptococci. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Nonbullous impetigo from an abrasion infected by group A beta-hemolytic streptococci. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Nonbullous impetigo secondary to group A beta-hemolytic streptococci. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Streptococcal impetigo from an infected insect bite. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Nonbullous impetigo resulting from an infected insect bite. See Media File 6 for a pure culture of group A beta-hemolytic streptococci from this lesion. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Group A beta-hemolytic streptococci pure culture from a lesion of nonbullous impetigo resulting from an infected insect bite. See Media File 5. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Bullous impetigo caused by Staphylococcus aureus. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Superficial flaccid bullae of bullous impetigo caused by Staphylococcus aureus. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
Peripheral collarettes of scale on the abdomen after rupture of bullae of bullous impetigo caused by Staphylococcus aureus. Courtesy of Professor David Taplin, Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, Fla.
 
 
 
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