What is the treatment for impetigo of the ear?

Treatment of Impetigo of the Ear

Topical mupirocin or retapamulin twice daily for 5 days is the first-line treatment for impetigo of the ear, with oral antibiotics reserved for extensive disease or when topical therapy is impractical. 1

Diagnosis

• Impetigo of the ear presents as honey-colored crusts (nonbullous form) or thin-roofed vesicopustules (bullous form)
• Nonbullous impetigo (70% of cases) is caused by Staphylococcus aureus and/or Streptococcus pyogenes
• Bullous impetigo (30% of cases) is exclusively caused by S. aureus

Treatment Algorithm

First-Line Treatment

1. Gentle debridement of crusts before medication application
2. Topical antibiotics (apply twice daily for 5 days):
   • Mupirocin 2% ointment 1, 2
   • Retapamulin ointment 1

When to Use Oral Antibiotics

Oral therapy is indicated when:

• Multiple lesions are present
• Infection is extensive
• Topical therapy is impractical
• During outbreaks affecting several people 1

Oral Antibiotic Options (7-day course)

For methicillin-susceptible S. aureus (MSSA):

• Dicloxacillin
• Cephalexin

For suspected or confirmed methicillin-resistant S. aureus (MRSA):

• Doxycycline
• Clindamycin
• Sulfamethoxazole-trimethoprim (SMX-TMP) 1

For streptococcal-only infections (confirmed by culture):

• Penicillin 1

Special Considerations

Perforated Tympanic Membrane

• Use only non-ototoxic preparations
• Avoid aminoglycoside-containing products 3
• Fluoroquinolones are safe options if tympanic membrane is not intact

Diabetic or Immunocompromised Patients

• Monitor closely for development of deeper infection
• Consider systemic antibiotics in addition to topical treatment 3
• Assess for signs of malignant otitis externa

Evidence Quality and Efficacy

• Topical mupirocin has shown clinical efficacy rates of 71-93% in clinical trials, with 94-100% pathogen eradication rates 2
• Mupirocin was as effective as oral erythromycin in clinical studies, with fewer side effects 2
• Topical therapy has been demonstrated to be as effective as oral antibiotics for localized impetigo 4

Potential Complications

• Poststreptococcal glomerulonephritis (rare complication)
• Systemic antibiotics should be used during outbreaks of poststreptococcal glomerulonephritis to eliminate nephritogenic strains 1
• Secondary infections if left untreated

Follow-up

• Improvement should be seen within 48-72 hours of starting treatment
• If no improvement after 72 hours, consider:
  1. Alternative diagnosis
  2. Antimicrobial resistance
  3. Need for culture and sensitivity testing
  4. Deeper infection requiring different management

Prevention

• Keep ears dry
• Use ear protection when showering or washing hair
• Consider acidifying ear drops after swimming if recurrent episodes occur 3

Impetigo of the ear typically resolves within 7-14 days with appropriate treatment, and complications are rare when properly managed.