What is the best treatment for combined facial Erysipelas and impetigo?

From the Guidelines

The best treatment for combined facial Erysipelas and impetigo is a course of antibiotics that cover both Streptococcus and Staphylococcus species, typically oral penicillin (500 mg four times daily) or amoxicillin (500 mg three times daily) for 7–10 days, as recommended by the Infectious Diseases Society of America 1. For patients with penicillin allergy, alternative antibiotics such as clindamycin may be considered. In severe cases or with extensive facial involvement, initial intravenous antibiotics may be necessary, followed by oral therapy once improvement begins. Alongside antibiotics, gentle cleansing of the affected areas with warm saline solution helps remove crusts and exudates. Topical mupirocin 2% ointment applied three times daily for 5-7 days can be added for localized impetigo lesions, as it is effective against both Staphylococcus aureus and Streptococcus pyogenes 1. Patients should be advised to avoid touching or scratching the affected areas, use separate towels and bedding, and maintain good hand hygiene to prevent spread. These infections require prompt treatment because facial involvement carries higher risk of complications including cavernous sinus thrombosis. Key considerations in management include:

• Identifying the causative pathogens through gram stain and culture, although treatment can be initiated without these results in typical cases 1
• Choosing an antibiotic regimen that covers both Staphylococcus and Streptococcus species
• Considering the use of topical antimicrobials for localized lesions
• Providing patient education on prevention of spread and promotion of wound healing.

From the FDA Drug Label

The efficacy of topical Centany (mupirocin ointment),2% in impetigo was tested in one study. Centany (mupirocin ointment),2% is indicated for the topical treatment of impetigo due to: Staphylococcus aureus and Streptococcus pyogenes.

The best treatment for impetigo is mupirocin ointment, as it has a clinical efficacy rate of 94-95% 2. However, for combined facial Erysipelas and impetigo, the FDA drug label does not provide direct information on the treatment of Erysipelas.

• Mupirocin ointment is indicated for the topical treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes 2. Since there is no direct information on the treatment of Erysipelas, a conservative clinical decision would be to consult additional resources or a medical professional for the best course of treatment for combined facial Erysipelas and impetigo.

From the Research

Treatment Options for Combined Facial Erysipelas and Impetigo

The treatment for combined facial Erysipelas and impetigo typically involves antibiotics, as both conditions are caused by bacterial infections.

• For impetigo, topical antibiotics such as mupirocin, retapamulin, and fusidic acid are commonly used 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.
• For Erysipelas, treatment is essentially based on parenteral penicillin G 4.
• In cases of combined facial Erysipelas and impetigo, the treatment approach may involve a combination of these options, taking into account the severity of the infection and the presence of any antibiotic-resistant bacteria.

Considerations for Antibiotic Resistance

• The increasing prevalence of antibiotic-resistant bacteria, such as methicillin-resistant S. aureus, macrolide-resistant streptococcus, and mupirocin-resistant streptococcus, must be considered when selecting a treatment option 3.
• Fusidic acid, mupirocin, and retapamulin are effective against methicillin-susceptible S. aureus and streptococcal infections, while clindamycin may be helpful in suspected methicillin-resistant S. aureus infections 3.
• Trimethoprim/sulfamethoxazole covers methicillin-resistant S. aureus infection, but is inadequate for streptococcal infection 3.

Alternative Treatment Options

• Topical disinfectants are inferior to antibiotics and should not be used as a primary treatment option 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.
• Treatments under development, such as minocycline foam and Ozenoxacin, a topical quinolone, may offer alternative options in the future 3.