What is the treatment for impetigo?

From the Guidelines

Impetigo should be treated with either topical mupirocin or retapamulin twice daily for 5 days for mild cases, while oral therapy is recommended for patients with numerous lesions or in outbreaks affecting several people. When considering treatment options, it's essential to weigh the severity and extent of the infection. For localized impetigo, topical antibiotics are often sufficient, but for more widespread or severe cases, oral antibiotics may be necessary 1. Some key points to consider when treating impetigo include:

• The use of gram stain and culture to identify the causative agent, although treatment without these studies is reasonable in typical cases 1
• The recommendation for oral therapy in cases with numerous lesions or outbreaks to decrease transmission 1
• The choice of oral antibiotics, such as dicloxacillin or cephalexin, for 7-day regimens, unless MRSA is suspected or confirmed, in which case doxycycline, clindamycin, or sulfamethoxazole-trimethoprim (SMX-TMP) may be used 1 It's crucial to prioritize good hygiene practices, including regular handwashing, avoiding sharing personal items, and keeping fingernails short, to prevent the spread of impetigo 1. In terms of specific treatment regimens, topical mupirocin or retapamulin twice daily for 5 days is recommended for bullous and nonbullous impetigo 1. For oral therapy, a 7-day regimen with an agent active against S. aureus, such as dicloxacillin or cephalexin, is recommended, unless cultures yield streptococci alone, in which case oral penicillin is the recommended agent 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:
  • 71% for mupirocin ointment (n=49) versus 35% for vehicle placebo (n=51) in the first study 2
  • 93% for mupirocin ointment (n=29) versus 78.5% for erythromycin (n=28) in the second study 2
• Pathogen Eradication Rates:
  • 94% for mupirocin ointment and 62% for vehicle placebo in the first study 2
  • 100% for both mupirocin ointment and erythromycin in the second study 2

From the Research

Impetigo Treatment Options

• Impetigo is a bacterial skin infection that can be treated with topical antibiotics such as mupirocin, retapamulin, and fusidic acid 3
• 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
• 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

Topical Antibiotic Treatment

• Mupirocin is a new, topical antibiotic effective for the treatment of impetigo, with clinical improvement seen in 85% to 100% of patients within 3 to 5 days 4
• Topical mupirocin treatment of impetigo is equal to oral erythromycin therapy, with similar clinical results and superior eradication of S aureus, including antibiotic-resistant S aureus 5
• Mupirocin ointment is a reliable topical alternative to oral antibiotic therapy for group A streptococcal and staphylococcal impetigo, with fewer adverse effects 6

Oral Antibiotic Treatment

• Oral or injectable antibiotics have been shown to be superior to topical treatment in the treatment of impetigo contagiosa, with options including erythromycin, phenoxymethyl penicillin, intramuscular benzathine penicillin G, clindamycin, cefaclor, and amoxicillin with clavulanic acid 7
• Intramuscular benzathine penicillin G has been associated with the highest cure rates, especially in studies specifically of streptococcal impetigo 7

Treatment Considerations

• Empiric treatment considerations have changed with the increasing prevalence of antibiotic-resistant bacteria, with methicillin-resistant S aureus, macrolide-resistant streptococcus, and mupirocin-resistant streptococcus all documented 3
• Fusidic acid, mupirocin, and retapamulin cover methicillin-susceptible S aureus and streptococcal infections, while clindamycin is helpful in suspected methicillin-resistant S aureus infections 3
• Trimethoprim/sulfamethoxazole covers methicillin-resistant S aureus infection, but is inadequate for streptococcal infection 3