What is the recommended treatment for impetigo?

Impetigo Treatment

For impetigo, topical mupirocin 2% ointment applied 2-3 times daily for 5-7 days is the first-line treatment for localized disease, while oral antibiotics are recommended for extensive infections. 1

Treatment Algorithm

Step 1: Assess Extent of Disease

• Localized impetigo (limited lesions, <100 cm² in adults or <2% body surface area in children)
• Extensive impetigo (multiple lesions, >100 cm² or >2% body surface area)

Step 2: Select Appropriate Treatment

For Localized Impetigo:

• First-line: Topical antibiotics
  • Mupirocin 2% ointment applied 2-3 times daily for 5-7 days 1, 2
  • Retapamulin 1% ointment applied twice daily for 5 days (for patients ≥9 months) 1, 3

For Extensive Impetigo or When Topical Therapy Is Impractical:

• Oral antibiotics (7-day course) 1:
  • For suspected methicillin-susceptible S. aureus (MSSA):
    • Dicloxacillin or cephalexin
  • For suspected methicillin-resistant S. aureus (MRSA):
    • Clindamycin 300 mg three times daily
    • Trimethoprim-sulfamethoxazole (TMP-SMX)
    • Doxycycline (avoid in children <8 years)
  • For coverage of both streptococci and MRSA:
    • Clindamycin alone
    • TMP-SMX or tetracycline plus amoxicillin
    • Amoxicillin-clavulanate 875/125 mg twice daily

Special Considerations

Pediatric Patients

• Mupirocin is safe and effective for children 4, 1
• Retapamulin is approved for children ≥9 months 3
• Avoid tetracyclines in children <8 years 4
• Adjust oral antibiotic dosing by weight 1

Treatment Failures

• Obtain cultures from active lesions to identify causative organism and antibiotic sensitivities 1
• Consider alternative antibiotics if no improvement within 3-5 days 1
• For recurrent infections (≥3 episodes), consider evaluation for underlying conditions 1

Evidence Quality and Considerations

The recommendations are based on high-quality guidelines from the Infectious Diseases Society of America 4 and clinical practice guidelines summarized by Praxis Medical Insights 1, supported by FDA drug labels 3, 2 and clinical research 5, 6, 7.

Topical mupirocin has been shown to be as effective as oral erythromycin in treating impetigo 6, 7, with fewer side effects. This makes it an excellent first-line choice for localized disease, balancing efficacy with minimizing antibiotic resistance risk.

Common Pitfalls to Avoid

• Failing to consider MRSA in recalcitrant cases 1, 5
• Using penicillin alone, which is inferior to other antibiotics for impetigo 1, 5
• Inadequate treatment duration leading to treatment failure 1
• Relying solely on topical therapy for extensive disease 1, 5
• Not addressing underlying conditions that may predispose to recurrent infection 1

Prevention Strategies

• Keep lesions covered when possible
• Use separate towels and linens
• Practice good hand hygiene
• Consider decolonization regimen for recurrent infections (intranasal mupirocin, chlorhexidine washes) 1

With appropriate treatment, impetigo typically resolves within 7-10 days without scarring, and complications such as poststreptococcal glomerulonephritis are rare 1, 5, 8.