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Impetigo

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Impetigo is a blistering skin infection and is usually caused by Staphylococcus aureus or Streptococcus pyogenes.

What does the rash look like?

The impetigo rash can either be bullous (with bullae or fluid-filled lesions larger than 0.5cm) or non-bullous (much more common). In the non-bullous form, there are vesicles. Often there is golden crusting on top the of rash.

Blisterimng vesicles and golden crusts of impetigo

What are the other symptoms?

The rash can be itchy or painful (but not commonly). Pyrexia and lymphadenopathy can occur in severe cases.

How is it diagnosed?

Impetigo is typically diagnosed clinically, but bacterial swabs may be sent if the infection is severe. MRSA may be the cause of resistant infections, so a swab could also be helpful here.

What is the course of the illness?

As the impetigo resolves, the golden crust dries and separates.

What are the possible complications?

Impetigo can spread very easily on contact and often spreads to other sites on the body.

Cellulitis, osteomyelitis or sepsis can occur, but more commonly in neonates with bullous impetigo.

It is also possible to develop post-streptococcal glomerulonephritis.

How long are patients infectious?

Patients are infectious until the crusting has all dried up. They should stay away from childcare until then.

What treatment should I offer?

Treatment is with antibiotics and depends on the extensiveness and resistance of the infection.

Impetigo with localized, superficial infection

Usually, these children are managed with topical antibiotics (mupirocin 2% TDS or fusidic acid 2% TDS) for 5-7 days. They are as effective as oral antibiotics.

Even a localized superficial infection in neonates should be treated with oral antibiotics (erythromycin for seven days) and a dermatologist should be consulted.

Widespread, cutaneous impetigo

One of the following oral antibiotics should be used for 7 days to treat this condition.

Flucloxacillin: 12.5-25 mg/kg QID; adult dose is 250-500mg QID

Erythromycin: 10mg/kg QID; adult dose is 250mg QID

Cephalexin: 25mg/kg QID; adult dose is 250-500mg QID

Localized, superficial impetigo with suspected MRSA infection

If the infection is resistant to the treatment above, or MRSA is suspected then treatment should be with one of the following antibiotics:

Clindamycin: 5mg/kg QID; dose in adults is 150-450mg QID

Trimethoprim/sulfamethoxazole: 4-5mg/kg BD; adult dose is 160mg BD (dose refers to trimethoprim component)

Impetigo with a deep infection or haematogenous spread

In children with pyrexia or systemic symptoms, IV antibiotics are indicated. Use one of the following antibiotics.

Flucloxacillin: 50mg/kg QID IV (max 2g)

Impetigo with a deep infection or haematogenous spread and suspected MRSA

These patients should be treated with vancomycin.

Vancomycin: 10mg/kg IV QID; adult dose is 500mg IV QID or 1g IV BD

Recurrent impetigo

Patients with recurrent infections consider intranasal antibiotics (mupirocin 2% TDS for 7 days) to treat nasal colonization.

Skin hygiene

Washing with soap and water twice a day is recommended to reduce skin bacteria.

References

Freeman M, Del Mar C. Impetigo. Best Practice, BMJ

McLinn S. A bacteriologically controlled, randomized study comparing the efficacy of 2% mupirocin ointment (Bactroban) with oral erythromycin in the treatment of patients with impetigo. J Am Acad Dermatol. 1990;22:883-885.

About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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