What is the first-line treatment for impetigo bullosa?

From the Guidelines

The first-line treatment for impetigo bullosa is topical mupirocin or retapamulin twice daily for 5 days. This recommendation is based on the strongest and most recent evidence available, which prioritizes the treatment of bullous and nonbullous impetigo with either topical mupirocin or retapamulin twice daily for 5 days 1.

Key Considerations

• The treatment should be guided by the severity of the infection and the presence of any underlying conditions that may affect the choice of antibiotic.
• For more extensive cases or when oral therapy is necessary, a 7-day regimen with an agent active against S. aureus is recommended, unless cultures yield streptococci alone, in which case oral penicillin is the recommended agent 1.
• In regions with a high prevalence of methicillin-resistant S. aureus (MRSA), alternative antibiotics like doxycycline, clindamycin, or sulfamethoxazole-trimethoprim (SMX-TMP) may be necessary based on local resistance patterns 1.

Management Strategies

• Patients should gently wash the affected areas with soap and water before applying medication.
• Avoid touching or scratching the lesions to prevent spread.
• Topical nasal mupirocin therapy may be used to eradicate S. aureus infections and limit spread during outbreaks 1.
• It is essential to be aware of the potential for resistance to mupirocin, especially high-level resistance, which can lead to failure of decolonization efforts 1.

Antibiotic Choices

• Dicloxacillin or cephalexin is recommended for methicillin-susceptible S. aureus infections 1.
• For patients allergic to penicillin or when MRSA is suspected, alternatives such as trimethoprim-sulfamethoxazole, doxycycline, or clindamycin may be used for susceptible isolates 1.

From the FDA Drug Label

INDICATIONS AND USAGE Centany (mupirocin ointment),2% is indicated for the topical treatment of impetigo due to: Staphylococcus aureus and Streptococcus pyogenes. The first-line treatment for impetigo bullosa is topical mupirocin ointment, 2%.

• The drug label for mupirocin ointment 2 indicates that it is used for the treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes.
• Clinical efficacy rates for mupirocin ointment in the treatment of impetigo were 94% 2.

From the Research

Impetigo Bullosa Management

The first-line treatment for impetigo bullosa includes:

• 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

Treatment Options

• Topical mupirocin and fusidic acid are effective and may be superior to oral antibiotics 4
• Oral antibiotics should be considered for patients with extensive disease 4
• Penicillin is seldom effective, and there is no clear preference among antistaphylococcal penicillins, amoxicillin/clavulanate, cephalosporins, and macrolides 4
• Cephalexin and dicloxacillin are equally effective for the treatment of staphylococcal skin and skin structure infections, including bullous impetigo 5

Evidence-Based Recommendations

• Topical antibiotics show better cure rates than placebo, with no significant difference between mupirocin and fusidic acid 6, 7
• Topical mupirocin is slightly superior to oral erythromycin 6, 7
• Penicillin is inferior to erythromycin and cloxacillin 6, 7
• There is a lack of evidence to support the use of disinfectant solutions for the treatment of impetigo 6, 7