QuestionPrescription
QuestionComment
why not Mupirocin? 
6793
User
subscriber
Jaundice Biopsy
QuestionComment
good q
39789
User
subscriber
A
QuestionComment
why is 7 days wrong in bnf they say 5-7 days for hydrogen peroxide
60950
QuestionComment
I agree, does anyone know why?
61020
User
subscriber
Supine Neoplasia
User
subscriber
Acute Kinin
Concept
Chapter
# Summary
 

Impetigo is a highly infectious superficial epidermal infection primarily caused by Staphylococcal or Streptococcal bacteria, commonly found in infants and school-aged children. Characteristic clinical signs include erythematous macules that vesiculate or pustulate, followed by superficial erosion with a golden crust. Although the diagnosis is usually clinical, a skin swab may be required in certain circumstances. Management is primarily via topical treatments such as fusidic acid, or oral flucloxacillin, and it's important to limit transmission by avoiding shared items and public places until 48 hours post-antibiotic treatment.
 

# Definition
 

Impetigo is a highly contagious superficial epidermal infection of the skin primarily caused by Staphylococcal and Streptococcal bacteria.
 

# Epidemiology
 

Impetigo most commonly occurs in infants and school-age children, with weekly rates of 84 per 100,000 children aged 0-4 in the UK. However, whilst less common in older individuals, it can affect individuals of any age. It affects boys and girls equally. 
 

# Aetiology
 

The aetiology of impetigo is mainly bacterial infections, specifically:
 

 - Staphylococcus aureus (80% of cases)
 - Group A beta haemolytic Streptococcus (Streptococcus pyogenes) (10% of cases)
 - In 10% of cases, both bacteria are present. 

These bacteria can invade the skin through minor cuts, insect bites, or abrasions, leading to infection.
 
Impetigo is very contagious and is spread through direct contact, with lesions appearing 4-10 days after contact. 
 
Bullous lesions are almost exclusively caused by Staphylococcus aureus, as this bacteria produces an exotoxin targeting desmoglein - 1 (an epithelial intercellular adhesion molecule). 

Risk factors include:

- Pre-existing skin conditions (i.e. eczema, cuts, burns, scabies)
- Immunosuppression
- Direct contact with an infected individual
- Environmental factors such as crowding, humidity and poor hygiene. 
 
# Classification
 
Impetigo can be sub-divided into:
 
 - Bullous: The child will have fluid filled lesions greater than 1 cm in diameter
 - Non-bullous: This is more common, and the child will not have bullae

It can also be divided based on aetiology:
 
 - Primary: Infection occurs in otherwise normal skin. 
 - Secondary: Infection is related to an underlying skin condition (i.e. eczema) or breach to the skin barrier (i.e. bite or cut).
 

# Signs and Symptoms
 

The primary clinical features of impetigo include:
 

 - Erythematous macule that vesiculates or pustulates
 - Superficial erosion with a characteristic golden crust
 - Impetigo may be bullous (causing large blisters) or non-bullous (causing sores)
 - Patches may be itchy or painful
 

These features are typically very infectious, prompting caution regarding close contact and shared items.
 

 [lightgallery]
 

# Differential Diagnosis
  

 - **Eczema Herpeticum**: Presents with rapid onset of painful, punched-out erosions with or without vesiculation on a background of atopic dermatitis. It may also exhibit systemic symptoms like fever and malaise.
 - **Herpes Simplex Virus (HSV) infection**: This may manifest as grouped vesicles on an erythematous base, usually accompanied by pain and itching. It can also cause systemic symptoms.
 - **Contact Dermatitis**: This involves erythematous, pruritic rash, usually in a pattern suggestive of a contact allergen.
 - **Tinea Corporis (Ringworm)**: Exhibits annular erythematous scaly plaques, often with central clearing.
 

# Investigations
 

While the diagnosis of impetigo is often clinical, based on the characteristic signs and symptoms, in certain cases, investigations may be warranted:
 

 - A skin swab may be necessary for microscopy, culture, and sensitivity, particularly in cases resistant to treatment or in the context of recurrent infections.
 

# Management
 

Impetigo can typically be managed effectively in primary care. Key management strategies include:
 

 - **Localised non-bullous impetigo:** topical treatment with hydrogen peroxide 1% cream (apply two or three times daily for 5 days) is first-line
  - If unsuitable, second-line options include fusidic acid or mupirocin (if fusidic acid resistance)
 - **Widespread non-bullous impetigo:**
  - Topical (fusidic acid/mupirocin) *or* oral antibiotics for 5 days, such as flucloxacillin
  - Clarithromycin (penicillin-allergic) or erythromycin (pregnancy) are alternatives
 - **Bullous impetigo, or impetigo in those systemically unwell or at high risk of complications:**
  - Oral antibiotics as above for up to 7 days


Advise general hygiene measures:
 
 - Avoid scratching the lesions 
 - Cover the affected areas and wash hands with soap and water 
 - Avoid sharing toys and towels whilst the infection is active 

**Children should be off school until all lesions are healed or until 48 hours after starting treatment.** 

Refer to secondary care if:
 

 * Suspected complications of impetigo (sepsis, glomerulonephritis, or deeper soft tissue infection) 
 * The patient is immunocompromised and infection is widespread

#  Complications 

Possible complications include:

- Worsening or spread of the infection  to cellulitis, ecthyma (a deeper form of impetigo), septic arthritis or sepsis
- Scarring 
- Acute post-streptococcal glomerulonephritis 
 
#  Prognosis 
 
Infection will resolve within 1-3 weeks, with this time reduced with proper treatment. Secondary impetigo is most likely to relapse if the underlying cause is chronic.

The risk of serious complications is low - however, it is most commonly seen in neonates or children with severe immunodeficiency. 
 

# NICE Guidelines 

[NICE Guidelines - Impetigo](https://cks.nice.org.uk/topics/impetigo/management/bullous-impetigo/)

# References

[NHS Information on Impetigo](https://www.nhs.uk/conditions/impetigo/) 

[Patient Info Impetigo](https://patient.info/doctor/impetigo-pro)
978
Picture
An example appearance of impetigo.
840
Impetigo.jpeg
images/6ukayq281665036171710.jpg
images/6ukayq281665036171710_256.jpg
images/6ukayq281665036171710_512.jpg
pCgKBoKcZ4hveHmBl6iHZ3h3CXyA8Zc=
3417
Impetigo
Topic
91
Paediatrics
# Drug choice feedback

This child is suffering from facial impetigo, an extremely common superficial skin infection usually caused by _Staphylococcus aureus_ or _Streptococcus pyogenes_. As the infection is localised and the patient is systemically well, as well as the infection being non-bullous and not around the eyes,  topical hydrogen peroxide 1% is first line as recommended by NICE. Fusidic acid can also be used, and is preferred if there is evidence of impetigo near the eyes. If impetigo were extensive, oral treatment with flucloxacillin would be recommended. 


# Dose/Route/Frequency/Duration feedback

The optimal frequency is two-three times a day for a duration of 5 days, as per NICE guidance.
6765
PrescriptionAnswer
PrescribeAnswerData
1 application
PrescribeAnswerData
fusidic acid 2% cream
PrescribeAnswerData
5 days
PrescribeAnswerData
three times daily (TDS)
PrescribeAnswerData
topical (TOP)
PrescriptionAnswer
PrescribeAnswerData
1 application
PrescribeAnswerData
hydrogen peroxide 1% cream
PrescribeAnswerData
7 days
PrescribeAnswerData
three times daily (TDS)
PrescribeAnswerData
topical (TOP)
PrescriptionAnswer
PrescribeAnswerData
1 application
PrescribeAnswerData
hydrogen peroxide 1% cream
PrescribeAnswerData
5 days
PrescribeAnswerData
twice daily (BD)
PrescribeAnswerData
topical (TOP)
PrescriptionAnswer
PrescribeAnswerData
1 application
PrescribeAnswerData
hydrogen peroxide 1% cream
PrescribeAnswerData
7 days
PrescribeAnswerData
twice daily (BD)
PrescribeAnswerData
topical (TOP)
PrescriptionAnswer
PrescribeAnswerData
1 application
PrescribeAnswerData
fusidic acid 2% cream
PrescribeAnswerData
5 days
PrescribeAnswerData
three times daily (TDS)
PrescribeAnswerData
topical (TOP)
PrescriptionAnswer
PrescribeAnswerData
1 application
PrescribeAnswerData
hydrogen peroxide 1% cream
PrescribeAnswerData
5 days
PrescribeAnswerData
three times daily (TDS)
PrescribeAnswerData
topical (TOP)
PrescriptionAnswer
PrescribeAnswerData
1 application
PrescribeAnswerData
fusidic acid 2% cream
PrescribeAnswerData
5 days
PrescribeAnswerData
twice daily (BD)
PrescribeAnswerData
topical (TOP)
Case Presentation: A 5-year-old girl attends her GP with her mother with non-bullous lesions on her cheeks and chin. They are mildly itchy.

## PH

Atopic Eczema

## DH

None (Severe allergy to Penicillin - Anaphylaxis)

## On examination

Child looks well and not in distress. The lesions are tiny pustules localised to the face, some have evolved into honey-coloured crusted plaques, most tend to be under 2cm in diameter. MRSA is not clinically suspected.

Temperature 36.7°C, HR 95, RR 25, BP 100/68, O<sub>2</sub> 94% RA, GCS 15, Weight 21kg

## Investigations

None

## Prescribing Request

Write a prescription for one topical drug that is most appropriate for treating her condition.