Treatment of Impetigo
For impetigo treatment, topical mupirocin 2% ointment applied three times daily for 5-7 days is the first-line therapy for limited lesions. 1, 2
First-Line Treatment: Topical Antibiotics
- Mupirocin 2% ointment applied three times daily for 5-7 days is highly effective for localized impetigo, with clinical efficacy rates of 71-93% in clinical studies 2, 1
- Retapamulin 1% ointment applied twice daily for 5 days is an effective alternative for limited impetigo 1, 3
- Topical antibiotics have been shown to be as effective as oral antibiotics for limited impetigo and have fewer side effects 4, 5
- FDA-approved mupirocin is specifically indicated for the topical treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes 2
Second-Line Treatment: Oral Antibiotics
Oral antibiotics should be used when:
For methicillin-susceptible S. aureus (MSSA) and streptococcal infections:
For suspected methicillin-resistant S. aureus (MRSA):
Special Considerations
- Penicillin alone is not effective for impetigo as it lacks adequate coverage against S. aureus 4, 6
- When streptococci alone are the cause (confirmed by culture), penicillin is the drug of choice, with macrolides or clindamycin as alternatives for penicillin-allergic patients 4
- Oral antibiotic dosing should be adjusted by weight for children 3
- Tetracyclines (doxycycline, minocycline) should not be used in children under 8 years of age 3, 6
- Complete the full course of prescribed antibiotics even if symptoms improve quickly to ensure complete resolution and prevent complications 1
Diagnostic Approach
- Impetigo can be either bullous (caused exclusively by S. aureus) or nonbullous (caused by S. aureus or Streptococcus pyogenes, or both) 4, 6
- Cultures of vesicle fluid, pus, or erosions should be obtained if:
Treatment Duration and Follow-up
- Topical treatment should be used for 5-7 days 1, 3
- Oral antibiotics should be given for 5-10 days 3, 7
- Re-evaluate if no improvement after 48-72 hours of therapy 3
- Lesions should be kept covered with clean, dry bandages and good personal hygiene maintained to prevent spread 3
Common Pitfalls and Caveats
- Topical disinfectants are inferior to antibiotics and should not be used 6, 5
- Consider empiric therapy for CA-MRSA in patients at risk for CA-MRSA infection, those who fail to respond to first-line therapy, or in areas with high local prevalence of CA-MRSA 1
- Increasing prevalence of antibiotic-resistant bacteria (MRSA, macrolide-resistant streptococcus, and mupirocin-resistant strains) may affect treatment choices 6
- Clinical experience suggests that systemic therapy is preferred for patients with numerous lesions or in outbreaks affecting several people to help decrease transmission of infection 4