Impetigo

Polly Buchanan
Community Dermatology Nurse Practitioner
Aetiology
• Pathogens
• Impetigo
• Staphylococcus aureus is the most common organism,
• Streptococcus pyogenes is the other pathogen involved, and on occasions both organisms
can be found together. In warmer
• Bullous impetigo - is nearly always caused by Staphylococcus aureus
• Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common
cause of impetigo, and is associated more often with the non-bullous form

• Transmission
• Impetigo
passed on from an infected individual
arise with no clear source of infection.
Enters the skin at the site of a minor skin injury
Secondary to another skin condition such as chickenpox
• Bullous impetigo - can affect intact skin
History
• Impetigo affects people of all races

• Impetigo can affect any age

• Non-bullous form is most common in children 2-5 years of age

• Bullous impetigo under the age of 2 years

• Males and females equally affected

• Impetigo is usually asymptomatic or mildly itchy

Clinical Findings
• Multiple lesions arise
• most commonly on exposed sites
such as the face (particularly
around the nose and mouth) and
limbs, or in the flexures, especially
the axillae

• Initial lesion is a thin-walled

vesicle with an erythematous
base (seldom observed)

• Golden yellow dried exudate or

yellow-brown crusts. Thicker in
streptococcal infections
Clinical Features

• Lesions extend gradually without central healing

• Lesions resolve without scaring within 2-3 weeks

• If there is an underlying skin condition such as eczema, lesions can become more
widespread. ( ie develop secondary impetigo)

• Mucosal involvement is uncommon

Bullous Impetigo
• Small or large bullae arise over a short period
of time, usually spreading locally on the face,
trunk, extremities, buttocks, or perineal
regions and may reach distal areas

• Bullae, which are less easily ruptured than in

the non-bullous form, initially contain clear
fluid, which then becomes cloudy. Once
ruptured, brown-yellow crusts develop

• Unlike with the non-bullous form, extension

occurs with central clearing

• The buccal mucous membrane can be

involved
Non Bullous Impetigo
Non Bullous Impetigo
Investigations
• Impetigo is usually diagnosed on the basis of the clinical appearance

• Poorly responsive or recurrent cases of impetigo

• Refer to GP
• Lesions should be swabbed for C&S to identify possible methicillin-resistant
Staphylococcus aureus (MRSA).

• Swabs are best taken from a moist lesion, or, in cases of bullous
impetigo from a de-roofed blister
Management: Step 1
• Step 1: General measures

• Provide a patient information leaflet on impetigo

• Cover affected areas where possible
• Wash hands regularly
• Use separate towels and flannels
• Avoid school until the lesions are healed or crusted over, or 48hours
after antibiotics are started
• Anti-microbial topical treatments - Hydrogen Peroxide
(Crystacide) , Benzoylkonium chloride, chlorhexidine products
Management: Step 2
• Step 2: mild / local infections

• First-line treatment is topical Fusidic Acid 2% cream for 7-10 days

• Topical Fusidic Acid 2% cream bd
• In cases of Fusidic Acid resistance use topical Mupirocin
Management: Step 3
• More widespread infection
• Use a systemic antibiotic for 7 days, either Flucloxacillin or
Erythromycin / Clarithromycin.
• Reasons for choosing the latter include cases of penicillin allergy, or if
there are concerns with regards to compliance
Complications

• Uncommon and most cases of impetigo settle fully within 2-3 weeks

• Streptococcal infection occasionally causes acute glomerulonephritis

Patient Group Direction – Fusidic Acid
2% Cream for Mild Localised Impetigo

•Inclusion Criteria:

•Adults and children aged 2 years or older with minor skin infection
•limited to a few lesions in one area of body.
•The rash consists of vesicles that weep and then dry to form yellow-
brown crusts.
•Must obtain parental/guardian consent for treating a child under the
age of 16 years.
•Patient must be present at consultation.
Patient Group Direction – Fusidic Acid
2% Cream for Mild Localised Impetigo
• Exclusion Criteria
• Multiple site skin infection.
• Children under the age of 2 years.
• Had impetigo within the last 3 months.
• Allergy to any component of the cream.
• Patient refuses treatment.
• Presenting with any underlying skin condition on the same area of the
body as impetigo.
• Concerns with regarding patient compliance with topical medication.
Patient Group Direction – Fusidic Acid
2% Cream for Mild Localised Impetigo

• Caution/ Need for further advice:

• Uncertain diagnosis
• Impetiginised eczema
• Eczema Herpeticum

• Action if Patient declines or is excluded:

• Refer patient to GP or OOHs for review
Fusidic Acid 2% Cream
• Legal Status: POM
• Route/ Method: Topical
• Dosage: Apply to lesions Four times daily for 7 days.
• Frequency: Apply Four times daily
• Duration of treatment Maximum treatment 7 days.
• Maximum or minimum treatment period: maximum of 7 days.
• Maximum of one supply in three months
• Quantity to Supply: 1 x 15gm tube
Case History 1
• 3 year old child
• Lesions on chin developed over 2
days
• Erythema++
• Vesicles+++
• Golden crusts+++
• Not painful or itchy

• Diagnosis?
• Management & Advice?
Case History 2
• 68 year old man
• History of Atopic Eczema
• Dry skin+++
• Lichenification+++
• Erythema++
• Itch+++
• Erosions+++
• Golden crusting +/-
• Excoriations+++

• Diagnosis?
• Management & Advice?
Case History 3
• 29 year old male
• Pain and tingling sensation+++
(before appearance of lesions)
• Erythema++
• Vesicles++
• Erosions++
• Crusting+

• Diagnosis?
• Management and Advice?
Eczema Herpeticum

• Rare
• Very Serious
• Patient Unwell +++
• Urgent referral
• Antiviral medication
Case Study 4
• 11 month old child
• Lesions appeared over 2-3 days
• Erythema++
• Vesicles++
• Crusts++
• Erosions+
• No itch

• Diagnosis?
• Management and Advice?
 References

• http://www.pcds.org.uk/