Journal of Infection (2016) 72, S61eS67

www.elsevierhealth.com/journals/jinf

Impetigo and scabies e Disease burden

and modern treatment strategies
Daniel K. Yeoh a, Asha C. Bowen a,b, Jonathan R. Carapetis a,b,*

a
Princess Margaret Hospital for Children, Perth, Western Australia, Australia
b
Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia

Available online 11 May 2016

KEYWORDS Summary Impetigo and scabies both present different challenges in resource-limited
Scabies; compared with industrialised settings. Severe complications of these skin infections are com-
Skin sores; mon in resource-limited settings, where the burden of disease is highest. The microbiology,
Impetigo; risk factors for disease, diagnostic approaches and availability and suitability of therapies also
Pyoderma; vary according to setting. Taking this into account we aim to summarise recent data on the
Children; epidemiology of impetigo and scabies and describe the current evidence around approaches
Paediatrics to individual and community based treatment.
ª 2016 Published by Elsevier Ltd on behalf of The British Infection Association.

Introduction Impetigo

Both impetigo and scabies are common infections of the Background

skin with a large global burden.1,2 In the industrialised
world, significant complications from impetigo and scabies
are rare whilst in resource-poor settings and certain mar-
ginalised communities, their collective impact is much
greater. There are several effective options for the treat-
ment of both impetigo and scabies. Despite this, challenges
remain in addressing the burden of disease on a community
level in regions where infection is endemic.
Impetigo is a common superficial skin infection which
predominantly affects young children.3,4 It is estimated
that more than 162 million children are suffering from
impetigo at any one time.2 The burden of disease is highest
in low-income countries and within marginalised popula-
tions in developed nations.2 Infection is caused by invasion
of the epidermis by bacteria colonising the skin following

* Corresponding author. Telethon Kids Institute, University of Western Australia, West Perth, Western Australia 6872, Australia.
Tel.: þ61 894897777.
E-mail addresses: daniel.yeoh@health.wa.gov.au (D.K. Yeoh), Asha.Bowen@menzies.edu.au (A.C. Bowen), Jonathan.Carapetis@
telethonkids.org.au (J.R. Carapetis).

http://dx.doi.org/10.1016/j.jinf.2016.04.024
0163-4453/ª 2016 Published by Elsevier Ltd on behalf of The British Infection Association.

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S62
minor trauma. Autoinoculation is common and the infection
is highly transmissible. Hot and humid climatic conditions,
poor access to water and possibly overcrowding are factors
which play a role in frequent impetigo transmission in
endemic areas.4
The bacterial aetiology of impetigo varies according to
region and continues to change over time. In tropical
climates Streptococcus pyogenes (Group A Streptococcus
or GAS) remains the major pathogen3,4 and co-infection
with Staphylococcus aureus is common.5 In temperate cli-
mates S. aureus has largely replaced S. pyogenes as the
predominant pathogen in impetigo6 and community ac-
quired methicillin resistant S. aureus (CA-MRSA) is of
increasing importance worldwide.6e8
Clinical manifestation, complications and diagnosis
Impetigo can present as bullous lesions or non-bullous,
papular lesions that go on to form a crust. Bullous impetigo
is caused by S. aureus whilst non-bullous lesions are associ-
ated with both S. pyogenes and S. aureus as described
above. Ecthyma is a deep form of impetigo in which ulcer-
ation extends into the dermis. In the developed world
impetigo is a common reason for presentations to primary
health care providers but it is generally a self-limiting con-
dition in this setting.9 In resource-limited settings severe
disease and complications of impetigo remain
problematic3,4,10
Invasive infections such as erysipelas (involving the
dermis and lymphatics), cellulitis (involving subcutaneous
tissue), osteomyelitis, septic arthritis and bacteraemia can
all complicate impetigo. S. pyogenes bacteraemia and
streptococcal toxic shock syndrome are commonly pre-
ceded by skin and soft tissue infection.11,12 S. aureus bac-
teraemia carries a high mortality and skin infection is an
important risk factor in settings where impetigo is
common.8,13
Where S. pyogenes is the predominant pathogen, impe-
tigo can also lead to significant immune-mediated compli-
cations. In endemic settings most cases of acute post-
streptococcal glomerulonephritis (APSGN) are preceded by
impetigo.14,15 Individuals with a history of APSGN in child-
hood are at increased risk of developing ongoing albumin-
uria and chronic kidney disease in later life.16,17 There is
also a plausible link between S. pyogenes skin infection
and acute rheumatic fever.18 This hypothesis is supported
by the presence of very high rates of rheumatic fever and
rheumatic heart disease in Aboriginal populations in
Australia wherein impetigo is pervasive and S. pyogenes
throat infection is uncommon.19
The diagnosis of impetigo is generally made clinically.
The use of clinical algorithms may aid in the identification
and treatment of impetigo in resource-limited settings. For
example, the WHO Integrated Management of Childhood
Illness (IMCI) skin algorithm has been assessed in Fiji and
demonstrated improvement in the clinical recognition of
impetigo.20 Elsewhere, flipcharts using high quality photo-
graphs and clinical descriptions are used to train health
care workers in diagnosing impetigo.21 Gram stain and cul-
ture of skin swabs to confirm the aetiological agent are
often recommended22 but adequate laboratory resources
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D.K. Yeoh et al.
are not always available in resource-limited settings and
treatment of typical cases without microbiology is
empiric.22 Nonetheless, in the current milieu of increasing
antimicrobial resistance,6 regional data on causative bacte-
riological agents and their antibiotic sensitivity profiles
remain vital to best direct empiric therapy and to monitor
for changing patterns of resistance.4
Treatment
When determining impetigo treatment, there are several
important factors including the extent of disease, commu-
nity wide prevalence, likely adherence to treatment and
known antimicrobial resistance. Most of the clinical trials
for impetigo treatment relate to limited or uncomplicated
impetigo, defined as fewer than 5 lesions. Where, impetigo
is extensive (greater than 5 lesions) or community preva-
lence is high, refer to the treatment section on extensive
impetigo.
Limited or uncomplicated impetigo
A Cochrane systematic review concluded that topical
antibiotics are the most effective treatment for limited
impetigo.23 This review included 68 randomised control tri-
als representing 5578 participants,23 finding that mupiro-
cin, fusidic acid and retapamulin were all superior to
placebo and there was no difference demonstrated be-
tween the most commonly studied topical agents: mupiro-
cin and fusidic acid. In addition, there was no significant
difference found in 7-day cure rates between topical and
oral antibiotics (excluding erythromycin which is inferior
to topical mupirocin) and topical antibiotic use was associ-
ated with fewer adverse events.23 The review also cited a
lack of supportive evidence for the use of disinfectant solu-
tions in the treatment of impetigo.23
There are several factors to consider when selecting a
topical antibiotic. Resistance to mupirocin and fusidic acid
among S. aureus isolates is increasing in association with
increased use of these agents.6,24 Although retapamulin
has demonstrated good in vitro activity against methicillin
resistant S. aureus (MRSA), its efficacy in clinical trials
against MRSA infections has been variable25,26 and it is
not approved for the treatment of MRSA infections. More-
over, S. aureus isolates with elevated minimum inhibitory
concentrations (MICs) to retapamulin have been described,
although the clinical significance of this is uncertain.27
There are calls to restrict the use of topical fusidic acid
in order to preserve the oral formulation as a useful agent,
in combination with rifampicin, for difficult-to-treat MRSA
infections.24 Topical fusidic acid is not available for use in
the USA and this is reflected in the Infectious Diseases Soci-
ety of America (IDSA) guidelines for skin and soft tissue
infection which recommend topical retapamulin or mupiro-
cin for uncomplicated impetigo.22
Extensive impetigo
Determining the optimal treatment of extensive impetigo,
particularly in resource-limited settings where the burden
of disease is highest, remains a challenge.4 It is generally
accepted that the use of systemic antibiotics for extensive
disease is practical and appropriate, yet there are limited
Impetigo and scabies
data comparing therapies for this indication4,23 and this is a
clear limitation of the Cochrane review on treatment of
impetigo.23 Furthermore the demonstrated frequency of
co-infection of S. pyogenes with S. aureus and the emer-
gence of CA-MRSA present additional challenges in selecting
appropriate therapy.5,6 Antibiotic treatment of affected in-
dividuals leads to resolution of impetigo lesions which likely
reduces transmission. Studies to date have not explored the
effect of antibiotics on rarer endpoints such as invasive
infection or APSGN due to the large sample size required.
Further work is needed to understand the full benefits of
treatment of extensive impetigo, and the potential risk of
inducing more widespread antimicrobial resistance if anti-
biotics are widely dispensed in highly-endemic
communities.
The available systemic treatment options for impetigo
have some limitations. Benzathine penicillin G (BPG) has
been widely used however it is poorly accepted in some
settings due to its intramuscular (IM) route of administra-
tion and its efficacy has been questioned with the emer-
gence of S. aureus as a pathogen in impetigo.4 Empiric
therapy with S. aureus cover is recommended for extensive
impetigo however oxacillins and first generation cephalo-
sporins lack activity against MRSA and may not be appro-
priate in settings where methicillin-resistance is
common.22 Amongst oral agents with activity against
MRSA, tetracyclines are contraindicated for use in children
and liquid formulations of lincosamides are unpalatable for
this age group. Co-trimoxazole (TMPeSMX) is an attractive
option in that it is cheap, licenced for use in children and
is available in a palatable liquid formulation. Although
the conventional wisdom is that TMPeSMX lacks activity
against S. pyogenes there are both in vitro25 and in vivo28
data to challenge this perception.29
A recent large clinical trial demonstrated non-inferiority
of oral co-trimoxazole compared to IM BPG in the treatment
of impetigo in Indigenous children in Northern Australia.10
The majority of participants (72%) had extensive disease
and S. pyogenes and S. aureus were isolated from 90%
and 81% of participants respectively. Clearance of S. pyo-
genes (but not S. aureus) was associated with clinical reso-
lution of sores, highlighting the primary role of S. pyogenes
in impetigo pathogenesis in this setting.10 The only other
study that has clear findings for this context compared
oral amoxicillin with oral erythromycin for treatment of
impetigo. Treatment success was achieved in 89% of both
groups, although microbiology was not available.30 Presum-
ably the high success rate seen in this study was also due to
the dominance of S. pyogenes in the microbiology of
impetigo.
Community treatment and prevention
Community based drug administration in certain scenarios
may reduce the burden of disease associated with impetigo
particularly in the setting of APSGN outbreaks and in
communities where scabies infestation is widespread. A
review of observational studies of such outbreaks in North-
ern Australia concluded that targeted treatment of children
with skin sores and household contacts of cases using BPG
was warranted.31 In communities where scabies is endemic,
targeted or mass community treatment of scabies has also
been shown to reduce the prevalence of impetigo.32,33
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S63
Bacterial decolonisation may play a role in the manage-
ment of patients with recurrent skin infections, the pre-
vention of post-surgical infections and in hospital based
MRSA control,22,34,35 however the utility of decolonisation
in the prevention of impetigo on a community level is un-
clear. Recent randomised controlled trials in military co-
horts assessing nasal mupirocin36 and topical
chlorhexidine37 respectively failed to demonstrate any
reduction in S. aureus skin and soft tissue infections. In
addition to the practical issues of implementing ongoing
topical decolonisation measures on a community level,
the widespread community use of mupirocin and/or chlor-
hexidine could result in the increased circulation of S.
aureus strains resistant to these agents and thus limit their
effectiveness.27,38,39 Recommendations for the use of
chemoprophylaxis to decolonise household contacts of
cases of invasive S. pyogenes disease vary and clear evi-
dence of efficacy in preventing invasive disease is lack-
ing.12,40 The role of broader community based S.
pyogenes decolonisation in the prevention of skin disease
has not been assessed.
It is clear that the greatest burden of impetigo and its
complications is borne by resource-limited populations,
where it is critical to focus on disease prevention. There
is ongoing work in the development of a vaccine against
GAS which could offer a cost-effective and practical avenue
for disease prevention, although a vaccine is not immi-
nent.41 In the interim, advocacy to improve access to
health services, sanitation and housing and to reduce over-
crowding in areas where impetigo is highly prevalent should
be a major focus in disease prevention. There is some evi-
dence that greater access to swimming pools42,43 and a
combination of hand-washing and daily bathing44 can
reduce the burden of impetigo. On a broader scale, as evi-
denced in the industrialisation of Asian countries such as
Singapore, complications such as APSGN can be virtually
eliminated in the setting of improved socioeconomic status,
housing and health services.45
Scabies
Background
Scabies is an infection of the skin caused by the mite Sar-
coptes scabiei var hominis. The adult mites burrow into
the epidermis and reproduce. In the epidermis, the mites
and their excreta produce a delayed hypersensitivity reac-
tion which is responsible for the rash and pruritus associ-
ated with scabies infestation. Transmission is
predominantly via prolonged skin-to-skin contact and
most commonly occurs between members of a household.46
Unsurprisingly scabies infection is associated with over-
crowding and socioeconomic disadvantage4,46,47 and chil-
dren carry the highest burden of disease.48 The
prevalence of scabies was found to range from 0.2% to
71.4% in a recent systematic review of population based
studies.48 The highest prevalence is seen in tropical re-
gions, such as Central America, the Pacific islands and
Northern Australia.48 In developed countries prevalence is
generally low but outbreaks amongst populations in institu-
tionalised care are well described.47
S64
Clinical manifestations, complications and
diagnosis
During primary infection, the appearance of symptoms is
delayed until 4 weeks following initial contact.46 Patients
present with a papular or vesicular eruption which is
intensely pruritic, usually worse at night. The mites are
most often found in web spaces of the fingers, on the
wrists, in the axillae, around the umbilicus and in the groin
or the popliteal fossa. Other family members may also have
pruritus. The distribution of infestation is different in in-
fants with involvement of the palms, soles and scalp.49
Scabies infestation is associated with significant compli-
cations related to secondary infection with bacteria. Bac-
terial infection, particularly with S. pyogenes and S.
aureus, is a well-recognised complication of scabies infes-
tation.1,4,5,13 The presence of scabies is associated with
complications of impetigo including invasive bacterial
infection and post-streptococcal glomerulonephritis.11,13,14
As discussed earlier, in endemic settings the treatment of
scabies at a community level has been shown to reduce
the prevalence and severity of skin sores32 and
haematuria.33
Crusted scabies is a severe form of scabies where the
host immune system fails to control the number of mites.50
It is characterised by crusted, hyperkeratotic lesions with
mite numbers reaching millions in some patients.50 Cases
classically occur in immunosuppressed patients and those
in institutional care although, in particular communities,
patients with no underlying risk factors are also affected.50
Because of the high mite burden, contacts of patients with
crusted scabies are at high risk of infestation themselves51
and this may drive community outbreaks.
Diagnosis of scabies is predominantly based on the
clinical findings of intense pruritus and a typical distribu-
tion of papules. Skin scrapings occasionally reveal mites,
ova or faeces, however microscopy is time consuming, of
low-yield and may be impractical in resource-limited
settings.46,52 While dermatoscopy is a potentially useful
diagnostic tool, the cost of equipment and the reliance
on appropriate training are limitations.52,53 As with impe-
tigo, clinical algorithms designed for use in resource-
limited settings have shown promise in increasing case
identification and warrant further evaluation.20 Certainly
comparison between studies examining prevalence and
treatment outcomes is hindered by the lack of consensus
criteria for the diagnosis of scabies.48,49 Further research
in designing simple and accurate diagnostic tests for scabies
is ongoing.
Treatment
Individual treatment
There are various topical therapies utilised in the treat-
ment of scabies. In a Cochrane review of randomised
control trials comparing scabies therapies, permethrin
was found to be the most effective topical therapy (supe-
rior to lindane and crotamiton).49 Benzyl benzoate is
another effective topical therapy that is preferred in
some resource-limited settings due to the relatively high
cost of permethrin, but is less well tolerated.46,54 The
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D.K. Yeoh et al.
application of topical scabies therapies can result in skin re-
actions and tolerability may be further reduced in humid
tropical climates.49
Ivermectin is an oral scabicide which was previously
reserved for cases of scabies refractory to topical therapy
but is increasingly seen as a useful agent for both individual
and community based treatment.55 As ivermectin is not
ovicidal a second dose is recommended 8e15 days following
the initial dose to prevent recrudescence.47 The efficacy of
oral ivermectin is superior to placebo and topical lindane
whilst trials comparing oral ivermectin to topical benzyl
benzoate have demonstrated mixed results.49,54 In the Co-
chrane review of scabies therapies, topical permethrin
was found to be superior to oral ivermectin although the
length of follow up in included trials ranged from 1 to 2
weeks only.49
Although ivermectin is an effective and well-tolerated
agent in the treatment of scabies there remain some
limitations to its use. Resistance is a potential concern
particularly in endemic communities.56 Also, there are
limited data demonstrating safety and tolerability of iver-
mectin in infants57 and it is not yet licensed for the treat-
ment of uncomplicated scabies in many regions.
Community treatment and prevention
The treatment of the close contacts of patients with
scabies is recommended in order to prevent re-infection
and further transmission although there is a lack of data
supporting this strategy.55 Topical permethrin is considered
first-line therapy,47 however poor compliance amongst con-
tacts has been identified as a barrier to the efficacy of this
approach.58 Oral ivermectin is an alternative agent for the
treatment of contacts which may prove effective and more
acceptable than topical therapies but this has yet to be as-
sessed in comparative trials.46,47 There is a clear need for
further research in this area with a recent Cochrane review
failing to identify any well-designed randomised trials as-
sessing prophylactic measures to prevent the transmission
of scabies.59
Mass drug administration (MDA) may be an alternative
approach to scabies control in settings where scabies is
endemic.46,55 This strategy has been explored as a control
measure using permethrin60,62 and ivermectin33,61,62
respectively with promising results. Notably, a recently
published randomised trial assessing the effectiveness of
scabies MDA in Fiji compared ivermectin MDA and
permethrin MDA with standard care (i.e. permethrin
treatment of cases and contacts) in three separate island
communities.62 There was a significant and sustained
reduction in scabies and impetigo in all three groups with
the most marked effect in the ivermectin group followed
by the permethrin MDA group.62 A significant reduction in
the community prevalence of scabies has previously been
demonstrated following the implementation of an iver-
mectin MDA program for the treatment of lymphatic filari-
asis in Tanzania.63 This study highlights the potential for
collaborative research in assessing the effects of MDA pro-
grammes on a number of neglected tropical diseases
including scabies.64
As with impetigo, the long-term control of scabies in
endemic settings is greatly dependent on addressing the
social determinants of health within these populations.
Impetigo and scabies
Crusted scabies treatment
It is recommended that patients with crusted scabies be
treated with a combination of topical permethrin and oral
ivermectin.47,51 Keratolytic agents should also be applied to
skin crusts to increase the efficacy of the topical scabi-
cide.47,51 As yet there are no randomised control trials
comparing treatment regimens for patients with crusted
scabies. With regards to community control, active case
identification and treatment of core transmitters with
crusted scabies within a population is a potential adjuvant
approach in endemic settings.51
Conclusions
The significant impact of scabies and impetigo on the
health of people in resource-limited settings has in the
past been under-recognised. Promisingly, there is growing
interest and advocacy concerning scabies and skin sores as
demonstrated by the recent formation of the International
Alliance for the Control of Scabies55 and the inclusion of
scabies on the WHO list of neglected tropical diseases in
2013. There is advocacy for impetigo to be included on
this list as well.2
There are safe and efficacious treatments available for
these common skin infections, yet in many areas where
disease burden is highest, little has changed with regards to
control. Ongoing research exploring risk factors and aeti-
ology, improved methods for diagnosis and approaches to
both individual and community based treatment is
required. Arguably, addressing the environmental and so-
cioeconomic factors which serve to perpetuate the high
rates of skin disease in certain communities is of chief
importance. Whilst in the industrialised world scabies and
impetigo are often considered trivial, ongoing efforts to
address the major impact of these infections in the
developing world remain extremely important.
Conflict of interest
The authors have no conflict of interest to declare.
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