Impetigo is a superficial skin infection that most commonly affects children 2 to 5 years of age. In the United States, more than 3 million cases of impetigo occur annually. Impetigo can be nonbullous (70%) or bullous (30%) and is most commonly caused by group A streptococcus and Staphylococcus aureus. Diagnosis of impetigo is based primarily on clinical examination and should be suspected in individuals with erythematous papules that progress to ruptured vesicles or bullae over 4 to 6 days, forming honey-colored crusts. Risk factors for impetigo include disruptions to the skin barrier, poor hygiene, crowded living environments, living in hot and humid climates, malnutrition, and diabetes. Topical mupirocin 2% ointment or retapamulin 1% ointment are the recommended initial treatments for mild, nonbullous and bullous impetigo. Oral antibiotics, such as dicloxacillin or cephalexin, should be targeted to group A streptococci and S. aureus and are recommended for outbreaks to decrease infection transmission or for severe, multilesional disease that does not respond to topical therapy within 3 to 5 days. Reducing the spread and recurrence of impetigo includes good hand hygiene, thoroughly washing objects used by people with impetigo, and refraining from returning to work or school until 12 to 24 hours after initiating antibiotic treatment or clinical improvement occurs.
Impetigo is a superficial bacterial skin infection that is most commonly caused by group A streptococcus and Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA). This article reviews the best available patient-oriented evidence to guide physicians in the diagnosis and management of impetigo.
WHAT'S NEW ON THIS TOPIC
| A 2022 systematic review concluded that there is good-quality evidence that topical antibiotics are equally or more effective than oral antibiotics in treating nonsevere impetigo. |
| Ozenoxacin 1% cream (available only as brand Xepi) is a topical quinolone approved by the US Food and Drug Administration in 2017 for the treatment of impetigo; however, it has been discontinued in the United States as of September 2025 and is expensive. It may be used as an alternative when there is concern for mupirocin and retapamulin resistance. |
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Diagnosis of impetigo is based primarily on clinical examination.5,20,22 | C | Expert opinion and consensus guidelines in the absence of clinical trials |
| Cultures of impetigo lesions should be considered in cases of inadequate response to therapy, recurrence, or diagnostic uncertainty.20,22 | C | Expert opinion and consensus guidelines in the absence of clinical trials |
| Topical antibiotic therapy with mupirocin 2% ointment is recommended for the initial treatment of mild, nonbullous and bullous impetigo.20,23,25,29 | A | Patient-oriented evidence with systematic reviews and IDSA guidelines |
| For severe, multilesional impetigo or disease that does not respond to topical antibiotic therapy, oral antibiotics targeted to group A streptococcus and Staphylococcus aureus are recommended.20,31,32 | A | Patient-oriented evidence with systematic reviews and IDSA guidelines |
| Good hand hygiene, washing of fomites, and prompt care of minor wounds can help decrease the spread of impetigo.8,23,37 | B | Limited-quality, patient-oriented evidence from randomized controlled trials and consensus guidelines |
IDSA = Infectious Diseases Society of America.
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 https://www.aafp.org/afpsort.
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