What is the recommended treatment for impetigo in children?

Treatment of Impetigo in Children

For children with impetigo, topical mupirocin 2% ointment applied 2-3 times daily for 5-7 days is the first-line treatment for limited, localized lesions, while oral antibiotics should be used for extensive disease. 1

Treatment Algorithm

Step 1: Assess Extent of Disease

• Limited disease (few lesions in a localized area):
  • Use topical therapy
• Extensive disease (multiple lesions or widespread areas):
  • Use oral antibiotics

Step 2: Treatment Options

Topical Treatment

• First-line: Mupirocin 2% ointment applied to affected areas 2-3 times daily for 5-7 days 1, 2
• Alternative: Retapamulin or fusidic acid (equal or superior efficacy to oral antibiotics for localized impetigo) 1

Oral Antibiotics (for extensive disease)

• First-line options:

  • Dicloxacillin: 12.5-25 mg/kg/day in 4 divided doses 1
  • Cephalexin: 25 mg/kg/day in 4 divided doses 1
  • For suspected MRSA:
    • Clindamycin: 10-20 mg/kg/day in 3 divided doses 3, 1
    • Trimethoprim-sulfamethoxazole (TMP-SMX): 8-12 mg/kg/day (based on trimethoprim) in 2 divided doses 3, 1

• Duration: Standard treatment is 7 days 1

• Important note: Tetracyclines (doxycycline, minocycline) should not be used in children under 8 years of age 3

Efficacy and Evidence

Topical mupirocin has been shown to be as effective as oral antibiotics for localized impetigo with fewer adverse effects 4, 5. In a randomized clinical trial, mupirocin demonstrated a trend toward more rapid clinical response compared to oral erythromycin 5.

A Cochrane review found that topical antibiotics showed better cure rates than placebo (RR 2.24,95% CI 1.61 to 3.13) and were slightly superior to oral erythromycin (RR 1.07,95% CI 1.01 to 1.13) 6.

Causative Organisms and Antibiotic Selection

Impetigo is caused by:

• Staphylococcus aureus (including MRSA)
• Streptococcus pyogenes (Group A Streptococcus)

When selecting antibiotics, consider:

• Local resistance patterns
• If MRSA is suspected, use clindamycin or TMP-SMX 3, 1
• Penicillin alone is not effective for impetigo 7, 6

Common Pitfalls to Avoid

1. Failing to consider MRSA in recalcitrant cases 1
2. Using penicillin alone, which has been shown to be inferior to other antibiotics 1, 6
3. Inadequate treatment duration - complete the full course of antibiotics 1
4. Relying solely on topical therapy for extensive disease 1
5. Using topical disinfectants instead of antibiotics - these are inferior and not recommended 7, 8

Prevention and Hygiene Measures

• Keep lesions covered when possible
• Use separate towels and linens
• Practice good hand hygiene
• Clean high-touch surfaces 1

When to Consider Culture

• For recurrent or treatment-resistant cases
• When MRSA is suspected
• In areas with high antibiotic resistance rates 1

For recurrent impetigo (3-4 episodes per year), evaluation for underlying immunodeficiency or neutrophil disorders may be warranted 1.