Impetigo: Diagnosis and Treatment



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Am Fam Physician. 2014 Aug 15;90(4):229-235.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.

  Patient information: See related handout on impetigo, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Impetigo is the most common bacterial skin infection in children two to five years of age. There are two principal types: nonbullous (70% of cases) and bullous (30% of cases). Nonbullous impetigo, or impetigo contagiosa, is caused by Staphylococcus aureus or Streptococcus pyogenes, and is characterized by honey-colored crusts on the face and extremities. Impetigo primarily affects the skin or secondarily infects insect bites, eczema, or herpetic lesions. Bullous impetigo, which is caused exclusively by S. aureus, results in large, flaccid bullae and is more likely to affect intertriginous areas. Both types usually resolve within two to three weeks without scarring, and complications are rare, with the most serious being poststreptococcal glomerulonephritis. Treatment includes topical antibiotics such as mupirocin, retapamulin, and fusidic acid. Oral antibiotic therapy can be used for impetigo with large bullae or when topical therapy is impractical. Amoxicillin/clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, minocycline, trimethoprim/sulfamethoxazole, and macrolides are options, but penicillin is not. Natural therapies such as tea tree oil; olive, garlic, and coconut oils; and Manuka honey have been anecdotally successful, but lack sufficient evidence to recommend or dismiss them as treatment options. Treatments under development include minocycline foam and Ozenoxacin, a topical quinolone. Topical disinfectants are inferior to antibiotics and should not be used. Empiric treatment considerations have changed with the increasing prevalence of antibiotic-resistant bacteria, with methicillin-resistant S. aureus, macrolide-resistant streptococcus, and mupirocin-resistant streptococcus all documented. Fusidic acid, mupirocin, and retapamulin cover methicillin-susceptible S. aureus and streptococcal infections. Clindamycin proves helpful in suspected methicillin-resistant S. aureus infections. Trimethoprim/sulfamethoxazole covers methicillin-resistant S. aureus infection, but is inadequate for streptococcal infection.

Impetigo is a common bacterial skin infection caused by Staphylococcus aureus, group A beta-hemolytic Streptococcus pyogenes, a combination of the two, or less commonly, anaerobic bacteria.1,2 In the United States, more than 11 million skin and soft tissue infections are caused by S. aureus annually.3 Impetigo is the most common skin infection in children two to five years of age, but persons of any age can be affected.4 One-third of skin and soft tissue infections in returning travelers are attributable to impetigo, usually secondary to infected mosquito bites.5

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Topical antibiotics are more effective than placebo and preferable to oral antibiotics for limited impetigo.

A

8, 11

Oral penicillin should not be used for impetigo because it is less effective than other antibiotics.

B

8, 12

Oral erythromycin and macrolides should not be used to treat impetigo because of emerging drug resistance.

B

8, 12

There is insufficient evidence to recommend topical disinfectants for the treatment of impetigo.

B

8

There is insufficient evidence to recommend (or dismiss) popular herbal treatments for impetigo.

C

24


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Topical antibiotics are more effective than placebo and preferable to oral antibiotics for limited impetigo.

A

8, 11

Oral penicillin should not be used for impetigo because it is less effective than other antibiotics.

B

8, 12

Oral erythromycin and macrolides should not be used to treat impetigo because of emerging drug resistance.

B

8, 12

There is insufficient evidence to recommend topical disinfectants for the treatment of impetigo.

B

8

There is insufficient evidence to recommend (or dismiss) popular herbal treatments for impetigo.

C

24


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Many bacteria inhabit healthy skin; some types, such as S. pyogenes and S. aureus, intermittently colonize the nasal, axillary, pharyngeal, or perineal areas.2,6 These bacteria can lead to infection of susceptible skin.6 Other factors that predispose to impetigo are skin trauma; hot, humid climates; poor hygiene; day care settings; crowding; maln

The Authors

HOLLY HARTMAN-ADAMS, MD, is an assistant professor of emergency medicine at West Virginia University Robert C. Byrd Health Sciences Center in Morgantown.

CHRISTINE BANVARD, MD, is an assistant professor of emergency medicine at West Virginia University Robert C. Byrd Health Sciences Center.

GREGORY JUCKETT, MD, MPH, is a professor of family medicine and director of the International Travel Clinic at West Virginia University Robert C. Byrd Health Sciences Center.

Address correspondence to Holly Hartman-Adams, MD, West Virginia University Robert C. Byrd Health Sciences Center, P.O. Box 9247, Morgantown, WV 26506 (e-mail: hhartman@hsc.wvu.edu). Reprints are not available from the authors.

REFERENCES

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19. Altabax (retapamulin) ointment [package insert]. Research Triangle Park, N.C.: GlaxoSmithKline; 2010. https://www.gsksource.com/gskprm/en/US/adirect/gskprm?cmd=ProductDetailPage&product_id=1320843776888&featureKey=603182. Accessed May 5, 2014.

20. Yan K, Madden L, Choudhry AE, Voigt CS, Copeland RA, Gontarek RR. Biochemical characterization of the interactions of the novel pleuromutilin derivative retapamulin with bacterial ribosomes. Antimicrob Agents Chemother. 2006;50(11):3875–3881.

21. Landrum ML, Neumann C, Cook C, et al. Epidemiology of Staphylococcus aureus blood and skin and soft tissue infections in the US military health system, 2005–2010. JAMA. 2012;308(1):50–59.

22. Ruby RJ, Nelson JD. The influence of hexachlorophene scrubs on the response to placebo or penicillin therapy in impetigo. Pediatrics. 1973;52(6):854–859.

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28. Ferrer successfully completes a phase III clinical trial in adult and paediatric patients with impetigo for novel antibacterial compound Ozenoxacin. June 5, 2013. http://www.drugs.com/clinical_trials/ferrer-successfully-completes-phase-i-clinical-trial-adult-paediatric-patients-impetigo-novel-15683.html. Accessed May 8, 2014.



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