From the Guidelines
Impetigo should be treated with either topical mupirocin or retapamulin twice daily for 5 days for bullous and nonbullous cases, or oral therapy for 7 days with an agent active against S. aureus for patients with numerous lesions or in outbreaks affecting several people. When considering treatment options, it's essential to note that gram stain and culture of the pus or exudates from skin lesions can help identify the cause, but treatment without these studies is reasonable in typical cases 1. Key considerations for treatment include:
- Topical antimicrobials, such as mupirocin or retapamulin, are recommended for bullous and nonbullous impetigo, applied twice daily for 5 days 1.
- Oral therapy is recommended for patients with numerous lesions or in outbreaks affecting several people, with a 7-day regimen of an agent active against S. aureus, such as dicloxacillin or cephalexin 1.
- When MRSA is suspected or confirmed, alternative oral antibiotics like doxycycline, clindamycin, or sulfamethoxazole-trimethoprim (SMX-TMP) are recommended 1. It's crucial to complete the full course of antibiotics, even if symptoms resolve quickly, to ensure the infection is fully eliminated and to prevent complications like cellulitis or post-streptococcal glomerulonephritis. During treatment, it's essential to practice good hygiene, such as avoiding touching or scratching lesions, using separate towels and linens, and washing hands frequently to prevent the spread of the infection. Improvement should be seen within 2-3 days of starting treatment, and patients should be monitored for any signs of complications or treatment failure 1.
From the FDA Drug Label
CLINICAL STUDIES The efficacy of topical mupirocin ointment in impetigo was tested in two studies. INDICATIONS AND USAGE Mupirocin ointment, 2% is indicated for the topical treatment of impetigo due to: Staphylococcus aureus and Streptococcus pyogenes.
Impetigo Treatment: Mupirocin ointment is indicated for the topical treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes 2 2.
- Clinical efficacy rates for mupirocin ointment in treating impetigo were 71% and 93% in two separate studies 2.
- Pathogen eradication rates for mupirocin ointment were 94% and 100% in the two studies 2.
- Mupirocin ointment can be used in pediatric patients, with clinical efficacy rates of 78% and 96% in two studies 2.
From the Research
Impetigo Treatment Options
- Topical antibiotics such as mupirocin, retapamulin, and fusidic acid are effective treatments for impetigo 3, 4, 5, 6
- Oral antibiotic therapy can be used for impetigo with large bullae or when topical therapy is impractical, with options including amoxicillin/clavulanate, dicloxacillin, cephalexin, clindamycin, doxycycline, minocycline, trimethoprim/sulfamethoxazole, and macrolides 3, 4
- Natural therapies such as tea tree oil, olive, garlic, and coconut oils, and Manuka honey have been anecdotally successful, but lack sufficient evidence to recommend or dismiss them as treatment options 3
Comparison of Topical Antibiotics
- Topical mupirocin and fusidic acid are equally effective, with a pooled risk ratio of 1.03 (95% CI 0.95 to 1.11) in 4 studies with 440 participants 5
- Topical mupirocin is slightly superior to oral erythromycin, with a pooled risk ratio of 1.07 (95% CI 1.01 to 1.13) in 10 studies with 581 participants 5
- Retapamulin and ozenoxacin are effective alternatives, but may entail higher cost 6
Antimicrobial Resistance
- Increasing worldwide antimicrobial resistance to existing topical agents is a concern, with rising resistance rates to commonly used antibiotics 5, 7
- Appropriate use of topical ozenoxacin can help eradicate impetigo while minimizing antimicrobial resistance 7
- Mupirocin has shown clinical efficacy against MRSA, but a bacterial culture is recommended to rule out resistance 6