Diagnosis and Treatment of Impetigo

CHARLES COLE, M.D., and JOHN GAZEWOOD, M.D., M.S.P.H.

University of Virginia School of Medicine, Charlottesville, Virginia

Impetigo is a highly contagious, superficial skin infection that most commonly affects children
two to five years of age. The two types of impetigo are nonbullous impetigo (i.e., impetigo con-
tagiosa) and bullous impetigo. The diagnosis usually is made clinically, but rarely a culture may
be useful. Although impetigo usually heals spontaneously within two weeks without scarring,
treatment helps relieve the discomfort, improve cosmetic appearance, and prevent the spread
of an organism that may cause other illnesses (e.g., glomerulonephritis). There is no standard
treatment for impetigo, and many options are available. The topical antibiotics mupirocin and
fusidic acid are effective and may be superior to oral antibiotics. Oral antibiotics should be
considered for patients with extensive disease. Oral penicillin V is seldom effective; otherwise
there is no clear preference among antistaphylococcal penicillins, amoxicillin/clavulanate,
cephalosporins, and macrolides, although resistance rates to erythromycin are rising. Topical
disinfectants are not useful in the treatment of impetigo. (Am Fam Physician 2007;75:859-64,
868. Copyright © 2007 American Academy of Family Physicians.)

I
Patient information: mpetigo is a highly contagious infec- Epidemiology
▲

A handout on impetigo, tion of the superficial epidermis that Impetigo usually is transmitted through
written by the authors of
this article, is provided on
most often affects children two to five direct contact. In a study in the United
page 868. years of age, although it can occur in Kingdom, the annual incidence of impetigo
any age group. Among children, impetigo was 2.8 percent in children up to four years
is the most common bacterial skin infec- of age and 1.6 percent among children five
tion and the third most common skin dis- to 15 years of age.4 Nonbullous impetigo
ease overall, behind dermatitis and viral accounts for approximately 70 percent of
warts.1,2 Impetigo is more common in chil- cases. Patients can further spread the infec-
dren receiving dialysis.1 The infection usu- tion to themselves or others after excoriat-
ally heals without scarring, even without ing an infected area. Infections often spread
treatment. Staphylococcus aureus is the most rapidly through schools and day care centers.
important causative organism. Streptococcus Although children are infected most often
pyogenes (i.e., group A beta-hemolytic strep- through contact with other infected children,
tococcus) causes fewer cases, either alone or fomites also are important in the spread of
in combination with S. aureus.3 impetigo. The incidence is greatest in the
There are two types of impetigo: nonbul- summer months, and the infection often
lous (i.e., impetigo contagiosa) and bullous. occurs in areas with poor hygiene and in
Nonbullous impetigo represents a host crowded living conditions.1,3
response to the infection, whereas a staphy-
lococcal toxin causes bullous impetigo and Diagnosis
no host response is required to manifest nonbullous impetigo
clinical illness.3 The diagnosis usually is Nonbullous impetigo begins as a single red
made clinically and can be confirmed by macule or papule that quickly becomes a
Gram stain and culture, although this is vesicle. The vesicle ruptures easily to form
not usually necessary. Culture may be use- an erosion, and the contents dry to form
ful to identify patients with nephritogenic characteristic honey-colored crusts that may
strains of S. pyogenes during outbreaks be pruritic (Figures 1 and 2). Impetigo often
of poststreptococcal glomerulonephri- is spread to surrounding areas by autoin-
tis or those in whom methicillin-resistant oculation. This infection tends to affect areas
S. aureus is suspected.3 subject to environmental trauma, such as the


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Impetigo

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Topical antibiotics such as mupirocin (Bactroban) and fusidic acid (not A 4, 8

available in the United States) are the preferred first-line therapy for
impetigo involving limited body surface area.
Oral antibiotics (e.g., antistaphylococcal penicillins, amoxicillin/clavulanate A 4, 8
[Augmentin], cephalosporins, macrolides) are effective for the
treatment of impetigo; erythromycin is less effective.
Oral antibiotics should be considered for patients with impetigo who C 4, 8
have more extensive disease and for disease associated with systemic
symptoms.
Oral penicillin V, amoxicillin, topical bacitracin, and neomycin are not B 4, 8
recommended for the treatment of impetigo.
Topical disinfectants such as hydrogen peroxide should not be used in B 4, 8
the treatment of impetigo.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-

dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, see page 789 or http://www.aafp.org/afpsort.xml.

extremities or the face. Spontaneous resolu- presentation is similar to that of primary

tion without scarring typically occurs in sev- nonbullous impetigo.1 Table 1 provides a
eral weeks if the infection is left untreated.5 selected differential diagnosis of nonbullous
A subtype of nonbullous impetigo is com- impetigo.1
mon (or impetiginous) impetigo, also called
bullous impetigo
secondary impetigo. This can complicate
systemic diseases, including diabetes mel- Bullous impetigo most commonly affects
litus and acquired immunodeficiency syn- neonates but also can occur in older children
drome. Insect bites, varicella, herpes simplex and adults. It is caused by toxin-producing
virus, and other conditions that involve S. aureus and is a localized form of staphylo-
breaks in the skin predispose patients to coccal scalded skin syndrome.5,6 Superficial
the formation of common impetigo. The vesicles progress to rapidly enlarging, flaccid

Figure 1. Nonbullous impetigo on the face. Figure 2. Nonbullous impetigo in the groin.

860  American Family Physician www.aafp.org/afp Volume 75, Number 6 ◆ March 15, 2007
 Impetigo

Table 1
Selected Differential Diagnosis of Nonbullous Impetigo

Diagnosis Distinguishing features

Atopic dermatitis Chronic or relapsing pruritic lesions and abnormally dry skin; flexural
lichenification is common in adults; facial and extensor involvement is
common in children
Candidiasis Erythematous papules or red, moist plaques; usually confined to mucous
membranes or intertriginous areas
Contact dermatitis Pruritic areas with weeping on sensitized skin that comes in contact with
haptens (e.g., poison ivy)
Dermatophytosis Lesions may be scaly and red with slightly raised “active border” or classic
ringworm; or may be vesicular, especially on feet
Discoid lupus Well-defined plaques with adherent scale that penetrates into hair follicles;
erythematosus peeled scales have “carpet tack” appearance
Ecthyma Crusted lesions that cover an ulceration rather than an erosion; may persist
for weeks and may heal with scarring as the infection extends to the dermis
Herpes simplex virus Vesicles on an erythematous base that rupture to become erosions covered
by crusts, usually on the lips and skin
Insect bites Papules usually seen at site of bite, which may be painful; may have
associated urticaria
Pemphigus foliaceus Serum and crusts with occasional vesicles, usually starting on the face in a
butterfly distribution or on the scalp, chest, and upper back as areas of
erythema, scaling, crusting, or occasional bullae
Scabies Lesions consist of burrows and small, discrete vesicles, often in finger webs;
nocturnal pruritus is characteristic
Sweet’s syndrome Abrupt onset of tender or painful plaques or nodules with occasional vesicles
or pustules
Varicella Thin-walled vesicles on an erythematous base that start on trunk and spread to
face and extremities; vesicles break and crusts form; lesions of different stages
are present at the same time in a given body area as new crops develop

Information from reference 1.

bullae with sharp margins and no surround- is present, and the condition may mimic
ing erythema (Figures 3 and 4). When the bul- child abuse.7 Table 21 provides a selected dif-
lae rupture, yellow crusts with oozing result. ferential diagnosis of bullous impetigo.
A pathognomonic finding is a “collar-
ette” of scale surrounding the blister roof at Prognosis and Complications
the periphery of ruptured lesions.5 Bullous No high-quality prognostic studies of
impetigo favors moist, intertriginous areas, impetigo are available. According to two
such as the diaper area, axillae, and neck recent nonsystematic reviews, impetigo usu-
folds. Systemic symptoms are not common ally resolves without sequelae within two
but may include weakness, fever, and diar- weeks if left untreated.2,5 Only five placebo-
rhea. Most cases are self-limited and resolve controlled randomized trials have been con-
without scarring in several weeks. Bullous ducted. Seven-day cure rates in these trials
impetigo appears to be less contagious than ranged from 0 to 42 percent.8 Adults seem to
nonbullous impetigo, and cases usually are have a higher risk of complications.2,5
sporadic.3 Bullous impetigo can be mistaken Acute poststreptococcal glomerulonephri-
for cigarette burns when localized, or for tis is a serious complication that affects
scald injuries when more extensive infection between 1 and 5 percent of patients with

March 15, 2007 ◆ Volume 75, Number 6 www.aafp.org/afp American Family Physician  861
Impetigo

nonbullous impetigo.1,4  Treatment with Treatment

antibiotics is not thought to have any effect The aims of treatment include relieving the
on the risk of poststreptococcal glomerulo- discomfort and improving cosmetic appear-
nephritis. Rheumatic fever does not appear ance of the lesions, preventing further spread
to be a potential complication of impetigo. In of the infection within the patient and to oth-
patients with chronic renal failure, especially ers, and preventing recurrence. Treatments
those on dialysis and transplant recipients, ideally should be effective, inexpensive, and
impetigo can complicate the condition. have limited side effects. Topical antibiotics
Other rare potential complications include have the advantage of being applied only where
sepsis, osteomyelitis, arthritis, endocardi- needed, which minimizes systemic side effects.
tis, pneumonia, cellulitis, lymphangitis or However, some topical antibiotics may cause
lymphadenitis, guttate psoriasis, toxic shock skin sensitization in susceptible persons.
syndrome, and staphylococcal scalded skin A Cochrane review of interventions for
syndrome.5 impe­tigo identified only 12 good-quality
studies of impetigo treatment. 8 In a
2003 meta-analysis that included 16 studies,
12 received a good-quality score.4 Most of
the studies addressed nonbullous impetigo,
although the limited data for bullous and
common impetigo suggest that similar con-
clusions may be drawn regarding treatment.

topical antibiotics versus placebo

Three studies found that topical antibiotics

are clearly more effective than placebo for the
treatment of impetigo.4,8 Most patients with
localized disease should receive mupirocin
(Bactroban) or fusidic acid (not available
in the United States) because they are effec-
tive and well tolerated. Data from four trials
show that they are equally effective.4,8 Data
on other topical antibiotics were limited, but
bacitracin and bacitracin/neomycin were less
effective. Adverse effects from topical anti-
Figure 3. Bullous impetigo.
biotics were uncommon and, when present,
were mild.8

oral antibiotics

Oral penicillin V was no more effective

than placebo in a single study of patients
with impetigo; however, the study was too
small (and therefore lacked adequate statisti-
cal power) to show a clinically meaningful
difference between the treatment and pla-
cebo groups, if one existed.8 Data comparing
other oral antibiotics with placebo are not
available.
Numerous studies compared various oral
antibiotics. Two systematic reviews showed
that lactamase-resistant, narrow-spectrum
Figure 4. Bullous impetigo. penicillins; broad-spectrum penicillins;

862  American Family Physician www.aafp.org/afp Volume 75, Number 6 ◆ March 15, 2007
 Impetigo

Table 2
Selected Differential Diagnosis of Bullous Impetigo

Diagnosis Distinguishing features

Bullous erythema Vesicles or bullae arise from a portion of red plaques, 1 to 5 cm in diameter,
multiforme on the extensor surfaces of extremities
Bullous lupus Widespread vesiculobullous eruption that may be pruritic; tends to favor the
erythematosus upper part of the trunk and proximal upper extremities
Bullous pemphigoid Vesicles and bullae appear rapidly on widespread pruritic, urticarial plaques
Herpes simplex virus Grouped vesicles on an erythematous base that rupture to become erosions
covered by crusts, usually on the lips and skin; may have prodromal symptoms
Insect bites Bullae seen with pruritic papules grouped in areas in which bites occur
Pemphigus vulgaris Nonpruritic bullae, varying in size from 1 to several centimeters, appear
gradually and become generalized; erosions last for weeks before healing
with hyperpigmentation, but no scarring occurs
Stevens-Johnson Vesiculobullous disease of the skin, mouth, eyes, and genitalia; ulcerative
syndrome stomatitis with hemorrhagic crusting is most characteristic feature
Thermal burns History of burn with blistering in second-degree burns
Toxic epidermal Stevens-Johnson–like mucous membrane disease followed by diffuse
necrolysis generalized detachment of the epidermis
Varicella Thin-walled vesicles on an erythematous base that start on trunk and spread to
face and extremities; vesicles break and crusts form; lesions of different stages
are present at the same time in a given body area as new crops develop

Information from reference 1.

cephalosporins; and macrolides were, in extensive impetigo and those with systemic
general, equally effective. Penicillin V and symptoms often are treated with oral anti-
amoxicillin were less effective than cepha- biotics, there were no studies comparing
losporins, cloxacillin, or amoxicillin/cla- oral and topical antibiotics in this subset
vulanate (Augmentin).4,8 One study found of patients. Oral antibiotics can be used,
cefuroxime (Ceftin) to be more effective however, based on expert opinion and tradi-
than erythromycin, and erythromycin resis- tional practice.8 Adverse effects, particularly
tance rates appear to be rising.4,8 nausea, are more common with oral anti-
biotics, especially erythromycin, than with
topical versus oral antibiotics topical antibiotics.8
According to several systematic reviews,
topical disinfectants
mupirocin was as effective as several oral
antibiotics (dicloxacillin [Dynapen], cepha- In a small, single study, topical disinfec-
lexin [Keflex], ampicillin). Oral antibiot- tants, such as hexachlorophene (Phisohex),
ics are recommended for patients who do were no better than placebo; and topical
not tolerate a topical antibiotic, and should antibiotics were found to be superior to
be considered for those with more exten- topical disinfectants in the treatment of
sive or systemic disease. Basic prescribing impetigo.8 Comparison of oral penicillin
information is summarized in Table 3. One V and hexachlorophene showed no dif-
study comparing fusidic acid and cefurox- ferences in cure rates or improvement in
ime found no difference in effectiveness, symptoms. Adverse effects from topical dis-
and both mupirocin and fusidic acid were infectants were rare and, when present, were
consistently more effective than oral eryth- mild; however, topical disinfectants are not
romycin.4,7 Although patients with more recommended.8

March 15, 2007 ◆ Volume 75, Number 6 www.aafp.org/afp American Family Physician  863
Impetigo
TABLE 3
Dosage, Duration, and Cost of Treatment Regimens for Impetigo

Antibiotic Dosing and duration of treatment Cost (generic)*†

Topical
Mupirocin 2% ointment Apply to lesions three times daily for three to $62
(Bactroban) five days
Oral
Amoxicillin/clavulanate Adults: 250 to 500 mg twice daily for 10 days 66 (37 to 76)
(Augmentin) Children: 90 mg per kg per day, divided, twice
daily for 10 days
Cefuroxime (Ceftin) Adults: 250 to 500 mg twice daily for 10 days 141 (41 to 88)
Children: 90 mg per kg per day, divided, twice
daily for 10 days
Cephalexin (Keflex) Adults: 250 to 500 mg four times daily for 10 days 70 (8 to 50)
Children: 90 mg per kg per day, divided, two to
four times daily for 10 days
Dicloxacillin (Dynapen) Adults: 250 to 500 mg four times daily for 10 days Only available as
Children: 90 mg per kg per day, divided, two to 500 mg: 7 to 86
four times daily for 10 days (26 to 48)
Erythromycin Adults: 250 to 500 mg four times daily for 10 days 10 (6 to 11)
Children: 90 mg per kg per day, divided, two to
four times daily for 10 days

*—Estimated cost to the pharmacist based on average wholesale prices (rounded to the nearest dollar) in Red Book.
Montvale, N.J.: Medical Economics Data, 2005. Cost to the patient will be higher, depending on prescription filling fee.
†—Drug cost is for lowest dosage presented when possible.

Data Search Address correspondence to John Gazewood, M.D.,

M.S.P.H., Department of Family Medicine, University of
For this review we searched Ovid Evidence- Virginia Health System, P.O. Box 800729, Charlottesville,
Based Medicine using the search term “impe- VA 22908 (e-mail: [email protected]). Reprints are not
tigo.” We also searched the National Guideline available from the authors.
Clearinghouse, the TRIP database, and Clini- Author disclosure: Nothing to disclose.
cal Evidence using the search term “impe- Figures provided by Kenneth Greer, M.D.
tigo.” We searched Medline (1996 to 2005)
using the Clinical Evidence search strategy.
REFERENCES

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tigo: an update. Int J Dermatol 2003;42:251-5.
CHARLES COLE, M.D., is an associate professor of clini- 2. Sladden MJ, Johnston GA. Common skin infections in
cal family medicine at the University of Virginia School children. BMJ 2004;329:95-9.
of Medicine, Charlottesville, and medical director of
3. Hirschmann JV. Impetigo: etiology and therapy. Curr
the Stoney Creek Family Practice, Nellysford, Va. Dr.
Clin Top Infect Dis 2002;22:42-51.
Cole earned his medical degree from the University of
4. George A, Rubin G. A systematic review and meta-
Maryland School of Medicine, Baltimore, and completed a
analysis of treatments for impetigo. Br J Gen Pract
residency in family medicine at the University of Virginia,
2003;53:480-7.
Charlottesville, where he also served as chief resident.
5. Mancini AJ. Bacterial skin infections in children:
JOHN GAZEWOOD, M.D., M.S.P.H., is an associate the common and the not so common. Pediatr Ann
professor of family medicine and residency program 2000;29:26-35.
director at the University of Virginia School of Medicine, 6. Johnston GA. Treatment of bullous impetigo and the
Charlottesville. He earned his medical degree from staphylococcal scalded skin syndrome in infants. Expert
Vanderbilt University, Nashville, Tenn., and completed a Rev Anti Infect Ther 2004;2:439-46.
family medicine residency at the University of Missouri– 7. Koning S, Verhagen AP, van Suijlekom-Smit LW, Morris A,
Columbia School of Medicine. After five years in private Butler CC, Van der Wouden JC. Interventions for impe-
practice, Dr. Gazewood earned a master of science in tigo. Cochrane Database Syst Rev 2003;(2):CD003261.
public health degree and completed faculty development 8. Mudd SS, Findlay JS. The cutaneous manifestations and
and geriatric fellowships at the University of Missouri– common mimickers of physical child abuse. J Pediatr
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864  American Family Physician www.aafp.org/afp Volume 75, Number 6 ◆ March 15, 2007