What is the treatment for impetiginization?

Treatment of Impetiginization

For impetiginization, topical mupirocin 2% ointment is the first-line treatment for limited lesions, while oral antibiotics are indicated for extensive disease or when topical therapy is impractical. 1

First-Line Treatment Options

Topical Therapy (Limited Disease)

• Mupirocin 2% ointment: Apply to lesions 3 times daily for 5-7 days 2, 1, 3
  • Clinical efficacy rates of 71-96% 3
  • Effective against both Staphylococcus aureus and Streptococcus pyogenes 3
  • Superior to oral erythromycin in clinical studies 3, 4

Oral Antibiotics (Extensive Disease)

For patients with extensive impetiginization, systemic symptoms, or when topical therapy is impractical:

1. First-line oral options (7-10 days of treatment):

   • Dicloxacillin: 250 mg 4 times per day (adults); 12 mg/kg/day in 4 divided doses (children) 2, 1
   • Cephalexin: 250-500 mg 4 times per day (adults); 25 mg/kg/day in 4 divided doses (children) 2, 1

2. For penicillin-allergic patients:

   • Clindamycin: 300-400 mg 3 times per day (adults); 10-20 mg/kg/day in 3 divided doses (children) 2, 1
   • Erythromycin: 250 mg 4 times per day (adults); 40 mg/kg/day in 4 divided doses (children) 2
     • Note: Some strains of S. aureus and S. pyogenes may be resistant to erythromycin 2

MRSA Considerations

If MRSA is suspected or confirmed:

• Topical: Continue mupirocin (still effective against many MRSA strains) 1
• Oral options:
  • Clindamycin: 300-450 mg 3 times per day (adults); 10-20 mg/kg/day in 3 divided doses (children) 2
  • Trimethoprim-sulfamethoxazole: 1-2 double-strength tablets twice daily (adults); 8-12 mg/kg/day based on trimethoprim component in 2 divided doses (children) 2
    • Note: TMP-SMX has inadequate streptococcal coverage 1, 5
  • Doxycycline: 100 mg twice per day (adults) 2
    • Not recommended for children <8 years of age 2
  • Linezolid: 600 mg twice daily (adults and children >12 years); 10 mg/kg/dose every 8 hours (children <12 years) 2

Special Pediatric Considerations

• For children with minor impetiginization, mupirocin 2% topical ointment is the treatment of choice 2, 1
• Tetracyclines (doxycycline, minocycline) should not be used in children <8 years of age 2
• For hospitalized children with complicated skin infections, options include:
  • Vancomycin (first choice) 2
  • Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (if local resistance rates are low) 2
  • Linezolid for children as noted above 2

Treatment Duration

• Topical therapy: 5-7 days 1
• Oral therapy: 7-10 days 1
• Duration should be based on clinical response 2

Prevention of Recurrence and Spread

• Keep draining wounds covered with clean, dry bandages 2
• Maintain good personal hygiene with regular bathing and handwashing 2
• Avoid sharing personal items (razors, linens, towels) 2
• Focus cleaning on high-touch surfaces 2
• Evaluate contacts for evidence of S. aureus infection 2

Clinical Pearls

• Re-evaluate patients in 24-48 hours if using tetracyclines or trimethoprim-sulfamethoxazole to verify clinical response 1
• Penicillin alone is not recommended as it is inferior to other antibiotics for impetiginization 6
• Topical disinfectants are inferior to antibiotics and should not be used 5
• Resistance patterns change over time and should be considered when selecting therapy 6