What is the recommended treatment for skin infections?

Recommended Treatment for Skin Infections

For skin infections, the first-line treatment is incision and drainage for abscesses plus appropriate antibiotic therapy, with selection based on infection severity, suspected pathogens, and local resistance patterns. 1, 2

Classification and Initial Approach

Uncomplicated Skin Infections

• Impetigo:

  • First-line: Topical antibiotics (mupirocin or fusidic acid) for localized lesions 1, 3
  • For widespread impetigo: Oral antibiotics (cloxacillin, dicloxacillin, cephalexin, or erythromycin) 4
  • Topical mupirocin has shown 92% pathogen eradication rate compared to 58% with vehicle alone 3

• Folliculitis, Furuncles, Small Abscesses:

  • Incision and drainage for abscesses (cornerstone of treatment) 2
  • Topical antibiotics for mild, localized infections 4

Complicated Skin Infections

• Cellulitis/Erysipelas:

  • First-line: β-lactams (amoxicillin-clavulanic acid, dicloxacillin, cefuroxime, or cephalexin) 1
  • For penicillin allergy: Clindamycin, doxycycline, or trimethoprim-sulfamethoxazole 1, 2

• Large Abscesses or IV Drug Use-Related Infections:

  • Incision and drainage plus empiric antibiotics 2
  • First-line oral options:
    • Trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily)
    • Doxycycline (100 mg twice daily)
    • Clindamycin (300-450 mg four times daily) 2

Antibiotic Selection Based on Suspected Pathogens

MRSA Coverage (When Suspected or Confirmed)

• Oral options:

  • Trimethoprim-sulfamethoxazole
  • Doxycycline/minocycline
  • Clindamycin (if local resistance <20%)
  • Linezolid (600 mg twice daily) for severe infections 2, 5

• IV options for severe infections:

  • Vancomycin (30-60 mg/kg/day in 2-4 divided doses)
  • Linezolid (600 mg every 12 hours)
  • Daptomycin (4-6 mg/kg once daily) 2, 5

Mixed Infections (Including Anaerobes)

• Amoxicillin-clavulanic acid
• Add metronidazole (500 mg every 8 hours) to regimens without anaerobic coverage 2

Treatment Duration

• Uncomplicated infections: 5-10 days
• Complicated infections: 10-14 days
• Necrotizing infections: 14-21 days 1, 2

Special Considerations

Animal or Human Bites

• First-line: Amoxicillin-clavulanic acid, ampicillin-sulbactam, or ertapenem
• For penicillin allergy: Doxycycline, trimethoprim-sulfamethoxazole, or fluoroquinolone plus clindamycin 1

Necrotizing Infections

• Immediate surgical debridement (critical)
• For group A streptococcal and clostridial infections: Clindamycin plus penicillin
• For mixed infections: Broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1

Practical Recommendations

1. For mild, localized skin infections:

   • Consider topical antibiotics (mupirocin or fusidic acid) 3, 6
   • Fusidic acid penetrates skin more effectively than other topical antibiotics 7

2. For moderate skin infections:

   • Oral antibiotics targeting likely pathogens
   • Amoxicillin-clavulanic acid, dicloxacillin, cefuroxime, or cephalexin for non-MRSA 1
   • Trimethoprim-sulfamethoxazole or doxycycline if MRSA suspected 2

3. For severe skin infections:

   • Hospitalization and IV antibiotics
   • Surgical consultation for possible debridement, especially with necrotizing infections 1, 2

Pitfalls to Avoid

• Failure to drain abscesses when indicated
• Not considering MRSA in recurrent or non-responsive infections
• Inappropriate use of topical antibiotics for chronic conditions (risk of resistance)
• Overlooking potential underlying conditions (diabetes, immunosuppression)
• Not adjusting therapy based on culture results 2, 8

Remember that incision and drainage alone may be sufficient for small abscesses, while antibiotics are necessary for surrounding cellulitis, systemic symptoms, or high-risk patients 2.