Management

Diagnosis:

• lesions can be swabbed and samples sent for culture
• NICE (1) do not suggest mandatory initial swabbing of lesions but note:
  • if a skin swab has been sent for microbiological testing:
    • review the choice of antibiotic when results are available and
    • change the antibiotic according to results if symptoms are not improving, using a narrow-spectrum antibiotic if possible

Topical treatment:

• topical fusidic acid or mupirocin
  • there is evidence that topical antibiotics may be slightly more effective than oral antibiotics for patients with limited non-bullous impetigo (2). Disinfecting treatments are not effective (2)
  • topical antibiotic therapy is indicated in localized cases without complications (3)
    • topical mupirocin is a very effective treatment option
    • topical fusidic acid cream an effective treatment for impetigo with very few side-effects, equally effective, in fact, as mupirocin.

Systemic treatment - if widespread

• systemic antimicrobials are the treatment of choice for widespread infections and infections complicated by systemic symptoms (3)
• recommended oral antibiotic choices are flucloxacillin or erythromycin, or a cephalosporin such as cefalexin or cefradine (4)

NICE suggest an algorithm for treatment based on features of the impetigo presenting to the clinician (1):

Open Image in Modal

Antibiotic treatments have been suggested by NICE (1):

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Open Image in Modal

Patient eduction:

• good handwashing techniques
• avoid scratching - cutting finger-nails may be useful

Notes:

• previously been stated that topical treatment for 7 days is generally adequate for limited disease - the maximum duration of topical treatment is 10 days (4)
  • if using systemic treatment and streptococcal infection is suspected then add phenoxymethylpenicillin to flucloxacillin (co-amoxiclav is an alternative to using phenoxymethylpenicillin and flucloxacillin together)

Reference:

1. NICE (February 2020).Impetigo: antimicrobial prescribing
2. Koning S etl al (2004). Interventions for impetigo. Cochrane Database Syst Rev 2004; (2)CD003261.
3. Brown J et al. Impetigo: an update. Int J Dermatol. 2003 Apr;42(4):251-5
4. Prescriber (2004); 15 (13): 35-40.
5. Public Health England (June 2021). Managing common infections: guidance for primary care