Approach

Most cases of bullous and non-bullous impetigo resolve without requiring medical care.[25]​ Standard treatment for local disease with no systemic manifestations is with topical antibiotics.[26]​ Oral antibiotics are reserved for patients with more severe or treatment-refractory disease.​[24][27]​​[28]​​​​ Intranasal antibiotics are used for those with chronic nasal carriage of causative bacteria. Skin hygiene measures and the use of antiseptic agents that reduce pathogenic bacteria density on the skin are useful for most patients.

Skin that has been broken either by minor trauma or as a result of another condition is particularly susceptible to infection, therefore any underlying cause (including wounds, dermatitis, insect bites, and scabies) should be excluded and treated.[1]​​

Neonates

Undertake antibiotic treatment in neonates in collaboration with a paediatric dermatologist or infectious disease specialist.

Patients presenting in the first month of life with non-bullous impetigo require oral antibiotics if MRSA is excluded or unlikely. Erythromycin is recommended as first-line treatment. Intravenous vancomycin is recommended if testing indicates the presence of MRSA.[26][29]

For neonates with bullous impetigo, parenteral antibiotic therapy with nafcillin, oxacillin, or clindamycin is recommended; vancomycin is recommended for cases of MRSA.[26][29]

Adults, children, and infants: superficial or limited infection

These patients have no evidence of deeper soft tissue involvement (abscess, cellulitis) or haematogenous spread (fever, constitutional symptoms). National Institute for Health and Care Excellence (NICE) guidelines in the UK recommend hydrogen peroxide cream as a first-line treatment.[24] Topical antibiotics such as mupirocin, fusidic acid, retapamulin, and ozenoxacin should be used if hydrogen peroxide cream is unsuitable (e.g., if impetigo is around eyes) or ineffective, except where there is resistance.[26][27][28]​​​​[30][31][32]

Adults, children, and infants: widespread cutaneous lesions

These patients have no evidence of deeper soft tissue involvement (abscess, cellulitis) or haematogenous spread (fever, constitutional symptoms). The oral antibiotics dicloxacillin or flucloxacillin, erythromycin, or a first-generation cephalosporin (e.g., cefalexin) are preferred agents.[24][27]​ Immunocompromised patients are at greater risk for developing a complicated course of infection; parenteral antibiotic treatment is a consideration for patients with widespread lesions and severe immune compromise.[26][29]​ If MRSA is suspected (cases of spontaneous abscess or cellulitis; lesions that do not resolve with recommended antibiotic treatment) and/or determined by antibiotic susceptibility testing, appropriate antibiotic choices include clindamycin, trimethoprim/sulfamethoxazole, or doxycycline.[27][28][33]​​

Adults, children, and infants: deep soft tissue involvement or haematogenous spread

These patients present with more extensive skin disease (abscess, cellulitis) or evidence of haematogenous spread (fever, constitutional symptoms). Parenteral antibiotic therapy with nafcillin, oxacillin, or clindamycin is recommended.[34]​ If MRSA is suspected (cases of spontaneous abscess or cellulitis; lesions that do not resolve with recommended antibiotic treatment) and/or determined by antibiotic susceptibility testing, vancomycin is the antibiotic of choice.[27]​ Alternatives to vancomycin include oritavancin, dalbavancin, and tedizolid. Consider collaboration with an infectious disease specialist (paediatric or adult) when treating infants, children, immunocompromised patients, or any patient poorly responsive to initial parenteral antibiotic treatment.

Intranasal antibiotics for chronic nasal bacterial colonisation

For patients who experience frequent recurrences of their impetigo, an intranasal antibiotic (applied to the nares at the same frequency as antibiotic skin application for 5 to 7 days of the month) is additionally used.[35]​ In the case where several family members other than the patient are affected by impetigo, intranasal antibiotic alone would be prescribed for the unaffected family member(s). In either case, the intention is to decrease nasal colonisation by bacteria, as the nasal reservoir can serve as a source for re-infection of an individual or spread of the infection to close contacts.

Skin hygiene measures

Twice-daily washing with soap and water is good general skin care for all patients with impetigo, as it helps to reduce the amount of bacteria on the skin. For older children and adults, particularly those with more widespread skin involvement, chlorhexidine can be a good antibacterial cleanser to add to their routine.[35]​ However, chlorhexidine is not recommended in neonates or children younger than 4 years (due to issues related to its potential toxicity with absorption).

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