What is the best treatment for a child with impetigo?

Treatment for Impetigo in Children

For children with impetigo, topical mupirocin 2% ointment is the first-line treatment for limited disease, while oral antibiotics such as clindamycin should be used for extensive disease. 1, 2

Treatment Algorithm Based on Disease Extent

Limited Disease (Few Lesions)

• First choice: Topical mupirocin 2% ointment applied to affected areas 3 times daily for 5-7 days 1, 2
  • FDA-approved specifically for impetigo caused by Staphylococcus aureus and Streptococcus pyogenes
  • Delivers high drug concentrations directly to infection site 3
  • As effective as oral antibiotics with fewer adverse effects 3

Extensive Disease (Multiple Lesions)

• First choice: Oral clindamycin (10-13 mg/kg/dose three times daily for 7-10 days) 1, 4

  • Excellent coverage against both MRSA and streptococci
  • Appropriate when topical therapy is impractical due to numerous lesions

• Alternative options (if clindamycin cannot be used):

  1. Combination therapy: Trimethoprim-sulfamethoxazole (TMP-SMX) plus amoxicillin 4
     • TMP-SMX alone has inadequate streptococcal coverage
  2. First-generation cephalosporins (for non-MRSA cases) 1
  3. Linezolid (for children >12 years: 600mg twice daily; <12 years: 10mg/kg three times daily) 4

Important Considerations

Causative Organisms

• Nonbullous impetigo (70% of cases): Caused by S. aureus or S. pyogenes 1
• Bullous impetigo (30% of cases): Caused exclusively by S. aureus 1
• Community-acquired MRSA (CA-MRSA) is an increasing concern 1

Age-Specific Restrictions

• Do not use tetracyclines (doxycycline, minocycline) in children under 8 years due to risk of inhibiting bone growth 4, 1

Monitoring Response

• Evaluate clinical response within 48-72 hours of starting therapy 1
• Expected resolution within 7-10 days with appropriate treatment 1
• If no improvement in 3-5 days, consider:
  • Obtaining bacterial culture and sensitivity testing
  • Alternative diagnosis
  • Possible need for different antibiotics 1

Prevention and Hygiene Measures

• Keep lesions covered when possible
• Use separate towels and linens for the affected child
• Practice good hand hygiene
• Avoid sharing personal items 1

Common Pitfalls to Avoid

1. Failing to consider MRSA in recalcitrant cases
2. Using penicillin alone (shown to be inferior to other antibiotics) 5
3. Inadequate treatment duration
4. Relying solely on topical therapy for extensive disease
5. Not addressing underlying conditions that may predispose to recurrent infection 1

Impetigo is highly contagious but responds well to appropriate antimicrobial therapy. While it typically resolves without scarring even without treatment, proper therapy reduces discomfort, improves appearance, and prevents spread to others 6.