From the Guidelines
Bullous impetigo should be treated with either topical mupirocin or retapamulin twice daily for 5 days, as recommended by the Infectious Diseases Society of America 1. This approach is based on the strongest and most recent evidence available, which prioritizes the use of topical antimicrobials for the treatment of bullous and nonbullous impetigo. The guidelines suggest that oral therapy may be considered for patients with numerous lesions or in outbreaks affecting several people, but topical treatment is generally recommended for localized cases 1.
Key Considerations
- The infection is caused by Staphylococcus aureus, occasionally Streptococcus pyogenes, which produce exfoliative toxins that split the epidermis, forming fragile blisters 1.
- Good hygiene practices, including regular handwashing, avoiding sharing personal items, and keeping fingernails short, help prevent the spread of the infection to other body areas and to other individuals.
- Gentle cleansing of affected areas with warm water and mild soap can help remove crusts and promote healing.
Treatment Options
- Topical mupirocin or retapamulin twice daily for 5 days is the recommended treatment for bullous impetigo 1.
- Oral antibiotics, such as cephalexin or dicloxacillin, may be considered for more extensive disease or in areas with high MRSA prevalence 1.
- Clindamycin or trimethoprim-sulfamethoxazole may be used as alternative options in cases where MRSA is suspected or confirmed 1.
From the FDA Drug Label
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.
Bullous impetigo is not explicitly mentioned in the provided drug labels. However, impetigo is mentioned, and it can be caused by Staphylococcus aureus and Streptococcus pyogenes, which can also cause bullous impetigo.
- The drug labels do provide information on the efficacy of mupirocin ointment in treating impetigo 2.
- Mupirocin ointment is indicated for the topical treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes 2. However, since bullous impetigo is not directly addressed, no conclusion can be drawn about the efficacy of mupirocin ointment in treating bullous impetigo.
From the Research
Definition and Types of Impetigo
- Impetigo is a highly contagious, superficial skin infection that most commonly affects children two to five years of age 3
- There are two principal types of impetigo: nonbullous (70% of cases) and bullous (30% of cases) 4
- Bullous impetigo is caused exclusively by Staphylococcus aureus and results in large, flaccid bullae, more likely to affect intertriginous areas 4
Treatment of Bullous Impetigo
- Topical antibiotics such as mupirocin, retapamulin, and fusidic acid are effective in treating impetigo, including bullous impetigo 4, 3, 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 4, 3
- Cephalexin and dicloxacillin have been shown to be equally effective in treating staphylococcal skin and skin structure infections, including bullous impetigo 7
Efficacy and Safety of Topical Antibiotics
- Topical mupirocin and fusidic acid have been shown to be equally effective in treating impetigo, with minimal adverse events 5, 6
- Retapamulin is an effective alternative, but may entail higher cost, and is indicated for lesions of impetigo that are colonized by MSSA and streptococcus S. pyogenes but not MRSA 6
- Ozenoxacin is also an effective alternative, but may entail higher cost 6
Resistance and Treatment Considerations
- Bacteria causing impetigo show growing resistance rates for commonly used antibiotics, highlighting the need for careful treatment considerations 5
- Mupirocin has shown clinical efficacy against MRSA, but a bacterial culture is recommended to rule out resistance 6
- Fusidic acid, available in other countries, is a non-FDA approved medication, and rising resistance rates represent a growing concern 6