What is the recommended treatment for returning impetigo?

Treatment for Recurring Impetigo

For recurring impetigo, oral clindamycin (300mg three times daily for 7-10 days) is the recommended treatment due to its excellent coverage against both MRSA and streptococci, which are common causes of treatment failure and recurrence. 1

Evaluation of Recurring Cases

When impetigo returns, consider these key factors:

1. Potential causes of recurrence:

   • Inadequate initial treatment duration
   • Antibiotic resistance (especially MRSA)
   • Persistent colonization
   • Underlying skin conditions
   • Close contact with infected individuals

2. Initial assessment:

   • Obtain bacterial culture and sensitivity testing to guide therapy
   • Evaluate for extent of disease (limited vs. extensive)
   • Check for signs of systemic involvement

Treatment Algorithm for Recurring Impetigo

For Limited Disease (< 100 cm²)

1. First-line treatment:

   • Topical mupirocin 2% ointment applied three times daily for 7-10 days 1, 2
   • Clinical efficacy rates of 71-93% demonstrated in clinical trials 2
   • Complete pathogen eradication rates of 94-100% 2

2. If previous treatment with mupirocin failed:

   • Consider retapamulin as an alternative topical agent 1
   • OR switch to oral therapy if topical treatment failure is suspected

For Extensive Disease or Topical Treatment Failure

1. First-line oral therapy:

   • Clindamycin 300mg three times daily for 7-10 days 1
   • Provides excellent coverage against both MRSA and streptococci

2. Alternative oral options:

   • For suspected/confirmed MRSA:

     • Trimethoprim-sulfamethoxazole (160-800mg twice daily for 7-10 days) 1
     • Note: TMP-SMX has inadequate streptococcal coverage and may need to be combined with a beta-lactam if streptococcal infection is suspected

   • For patients >8 years without MRSA:

     • Doxycycline (100mg twice daily for 7-10 days) 1
     • First-generation cephalosporins like cephalexin 1, 3
     • Amoxicillin/clavulanate 3

Special Considerations for Recurring Cases

• Extended treatment duration: Consider extending treatment to the full 10 days for recurring cases 1

• Decolonization strategies:

  • Treat household contacts who may be carriers
  • Consider nasal mupirocin for S. aureus nasal carriers
  • Implement hygiene measures (separate towels, frequent hand washing)

• Evaluate for underlying conditions:

  • Eczema or other dermatoses that may predispose to recurrence
  • Immunocompromised states
  • Diabetes or other systemic conditions

Monitoring and Follow-up

• Evaluate clinical response within 48-72 hours of starting therapy 1
• If no improvement is seen within 3-5 days:
  • Obtain bacterial culture and sensitivity testing if not already done
  • Consider alternative diagnosis
  • Evaluate need for intravenous antibiotics in severe cases 1

Prevention of Recurrence

• Keep lesions covered when possible 1
• Use separate towels and linens 1
• Practice good hand hygiene 1
• Avoid sharing personal items 1, 3
• Prompt identification and treatment of cases in close contacts 1

Common Pitfalls in Managing Recurring Impetigo

• Failure to consider MRSA as the causative organism in recalcitrant cases 1
• Using penicillin alone, which has been shown to be inferior to other antibiotics 1, 4
• Inadequate treatment duration, especially for recurring cases 1
• Relying solely on topical therapy for extensive disease 1, 5
• Not addressing underlying conditions that may predispose to recurrent infection 1
• Ignoring household contacts who may be asymptomatic carriers

Remember that while impetigo usually resolves within 2-3 weeks even without treatment, appropriate antibiotic therapy significantly shortens the duration of illness and prevents spread to others 1, 3.