Visual Journal of Emergency Medicine 32 (2023) 101754

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Visual Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/visj

Visual Case Discussion

Extensive Non-Bullous Facial Impetigo in an Adult

Persiana S. Saffari a, *, Carol Lee b, Hemang Acharya b
a
David Geffen School of Medicine, University of California, Los Angeles, CA, USA
b
West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA, USA

A R T I C L E I N F O

Keywords:
Impetigo
Non-bullous impetigo
Skin infection
Group A Strep
Mupirocin

Discussion include cloxacillin (for methicillin-sensitive strains) or

Impetigo can present in bullous and non-bullous forms, with the
latter making up 70% of all impetigo infections affecting adults and
children.1 Non-bullous impetigo is an extremely contagious and com­
mon soft tissue skin infection of the superficial layers of the epidermis. It
is typically caused by gram-positive bacteria, most notably
beta-hemolytic group A streptococcus or staphylococcus aureus, and
manifests as a pruritic, painful rash with erythematous vesicles or pus­
tules.2 Upon rupturing, the remaining erosions produce a honey colored
exudate that creates the characteristic crusting seen in infected patients.
Improper hygiene and malnutrition are predisposing factors to
non-bullous impetigo, which is prominently seen in areas with exposed
skin, including the face and extremities.
Bacterial cultures are collected in suspected cases of non-bullous
impetigo to confirm diagnosis as well as tailor treatment regimen
when there is a concern for methicillin-resistant staphylococcus aureus
(MRSA) based on patient history. Treatment is often a combination of
systemic antibiotics, saline or benzoyl peroxide soaks, and topical
mupirocin. Treatment of non-bullous impetigo consists of oral antibi­
otics that are employed when at least one of the following criteria are
met: there are greater than five lesions in the affected area, lymphade­
nopathy, systemic signs of infection, oral cavity lesions, or involvement
of deep tissue.1,2 When multiple of these criteria are met and the affected
area is extensive, IV antibiotics and hospitalization may be warranted to
observe some improvement with systemic therapy prior to discharge.
Antibiotics that are beta-lactamase resistant are first-line, with oral
cephalexin being a standard selection. Some alternative antibiotics
trimethoprim-sulfamethoxazole and doxycycline to treat MRSA.
Without treatment, the infection generally resolves within 14-21 days –
and up to 20% of cases resolve spontaneously; with treatment, patients
typically experience resolution of symptoms within ten days.
We present a case of extensive facial non-bullous impetigo in this
visual case discussion.
Visual Case Discussion
A 39-year-old male with a history of anxiety and depression pre­
sented to the Emergency Department (ED) with a pruritic, burning
yellow facial rash that spread to his forehead, eyelids, cheeks, nose, and
chin within 24 hours. Five days prior to his presentation, the patient was
in a fight and received multiple blows to the face that resulted in a nasal
contusion and periorbital hematoma. The injuries were slowly healing
until the patient went to the beach one day prior to the ED presentation;
he noted falling asleep on the sand for one hour, and waking up from a
burning sensation he felt on his face. The patient noticed skin redness
that encompassed his face and anterior neck, which he attributed to
sunburn, as well as a yellow, draining rash across his nose and bilateral
cheeks. The patient recalls vomiting twice that day, but not since. That
same evening, he attempted to clean the affected rash area using a facial
cleansing wipe, but awoke the following morning and noticed the rash
had spread across the remainder of his face. The rapid spread of the rash,
the worsening burning and itching sensation on his face, and increased
stiffness with jaw and extraocular eye movements prompted his visit to
the ED.

* Corresponding author.
E-mail address: psaffari@mednet.ucla.edu (P.S. Saffari).

https://doi.org/10.1016/j.visj.2023.101754
Received 15 May 2023; Received in revised form 3 June 2023; Accepted 19 June 2023
Available online 22 June 2023
2405-4690/© 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
P.S. Saffari et al.
The patient has no other significant past medical history. He had an
upper left eyebrow laceration that was repaired with sutures six months
prior. The patient takes his fluoxetine and hydroxyzine as prescribed to
manage his depression and anxiety, respectively. There were no recent
changes to dosage and he denied taking any supplements. He has no
known allergies and stated that an allergy test from three years ago
showed no sensitivities. He has a ten pack-year history of smoking to­
bacco and has consumed a six-pack of beer per day for the last three
months.
Upon physical examination, the patient had a heart rate of 113,
temperature of 37.4◦ C, blood pressure of 132/87, and pulse oxygen 99%
on room air. The facial rash affected his forehead, eyelids, cheeks, nose,
skin surrounding the lips, and chin (Fig. 1). The yellow rash contained
diffusely crusted lesions with draining fluid from multiple sites and a
notable sunburn that was tender to light palpation. The patient had no
conjunctivitis or intra-oral lesions, but did have cervical lymphade­
nopathy. The remainder of the physical exam was unremarkable.
Lab work revealed a white blood cell count of 17,560 per microliter.
The remainder of the lab values from the complete blood count and basic
metabolic panel were within normal limits. HIV, MRSA, RPR, HSV, and
VZV tests returned negative. Given that the patient was in an altercation
that caused facial contusions five days prior, a facial and neck computed
tomography (CT) scan was collected. The CT scan showed a soft tissue
skin infection spreading across the face without invasion into deep fascia
and without any discrete abscess, sinus infection, or odontogenic
infection. There was also prominent lymphadenopathy. A nasal fracture
was seen on the CT scan – likely secondary to the patient’s altercation –
that did not require repair per surgical consult.
The patient was initially given intravenous lactated ringers and
vancomycin, piperacillin-tazobactam, and clindamycin to have broad
microbial coverage while cultures were pending. He was later
Fig. 1. Draining, full facial impetigo seen on ED presentation.
2
Visual Journal of Emergency Medicine 32 (2023) 101754
transitioned to vancomycin and ceftriaxone once wound gram stain and
wound culture returned positive for Group A Streptococcus. The patient
also had a 10-minute benzoyl peroxide soak applied to his face prior to
application of mupirocin ointment three times per day. After two days of
in-patient treatment, the patient’s rash improved and he was discharged
from the hospital on oral cefadroxil, for which he was instructed to
complete a ten-day antibiotic course to treat his soft tissue skin infection
and use mupirocin until the non-bullous facial impetigo resolved.
Questions and Answers with a Brief Rationale
Question Type: True & False
Impetigo is highly contagious and requires adequate coverage of
actively draining lesions and proper hand hygiene in order to avoid
spread of infection.
a False
b True
Correct Answer = b: True
Explanation: The contagious nature of impetigo is why antibiotics –
whether they be topical, systemic, or a combination – are so beneficial in
the treatment regimen of this soft-tissue skin infection. In addition to
increasing recovery speed; antibiotics reduce bacterial transmission to
distant sites via autoinoculation. The decreased opportunity of trans­
mission is also accomplished by proper care of draining lesions such that
the fluid does not cause impetigo in other exposed areas.
Question Type: Multiple choice
A previously healthy 33-year-old male presents with findings of
acute onset impetigo. Testing for which of the following pathologies
below should be included in the initial patient work-up?
a Coxsackie virus
b Human Immunodeficiency Virus (HIV)
c Rubella
d Urinary tract infection
Correct Answer = b: HIV
Explanation: Those with compromised immune systems are more
likely to develop impetigo. Patients with diabetes, HIV, and cancer un­
dergoing chemotherapy all have a heightened risk of infection from
Group A streptococcus and staphylococcus aureus. Adult impetigo in
immunocompromised patients can be triggered by trauma, changes in
facial care regimen, or reactivation of a latent virus (Herpes Simplex).
Therefore, it is critical to determine the patient’s HIV status in order to
best manage treatment plans.
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approval of proofs. We confirm that we have provided a current, correct 1 Pereira LB. Impetigo - review. An. Bras. Dermatol. 2014;89:293–299.
2 Nardi NM, Schaefer TJ. Impetigo. StatPearls. StatPearls Publishing; 2023.
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