What is the best treatment for impetigo in the nose?

Treatment of Impetigo in the Nose

Topical mupirocin 2% ointment applied three times daily for 5-7 days is the first-line treatment for impetigo in the nose. 1, 2, 3

First-Line Treatment

• Mupirocin 2% ointment should be applied to the affected area three times daily for 5-7 days 1, 2
• Clinical efficacy rates with mupirocin are excellent (71-93%) with pathogen eradication rates of 94-100% 3
• Mupirocin is specifically indicated for the topical treatment of impetigo caused by Staphylococcus aureus and Streptococcus pyogenes 3
• Clinical improvement should be seen within 3-5 days of starting treatment 4

Second-Line Treatment Options

• Oral antibiotics should be used when:

  • Impetigo is extensive or involves multiple sites in the nose 1, 2
  • Topical therapy is impractical 2
  • Treatment with topical antibiotics has failed 2
  • Systemic symptoms are present 2

• For Methicillin-Susceptible S. aureus (MSSA):

  • Dicloxacillin 250 mg four times daily for adults 1
  • Cephalexin 250-500 mg four times daily for adults 1, 2

• For Methicillin-Resistant S. aureus (MRSA):

  • Clindamycin 300-450 mg three times daily 1, 2
  • Trimethoprim-sulfamethoxazole (TMP-SMX) 1, 2
  • Doxycycline (not for children under 8 years) 1, 2

Diagnostic Considerations

• Impetigo in the nose typically presents as erythematous papules that rapidly evolve into vesicles and pustules 2
• Cultures should be obtained if:
  • There is treatment failure 2
  • MRSA is suspected 2
  • In cases of recurrent infections 2

Treatment Duration and Follow-up

• Topical treatment should be continued for 5-7 days 1, 2
• Oral antibiotics should be administered for 5-10 days 2
• Re-evaluate if no improvement after 48-72 hours of therapy 2
• Lesions should be kept covered when possible to prevent spread 2

Special Considerations for Nasal Impetigo

• For recurrent furunculosis or impetigo with nasal colonization, application of mupirocin ointment twice daily in the anterior nares for the first 5 days each month can reduce recurrences by approximately 50% 5
• For persistent or recurrent cases with nasal colonization, clindamycin 150 mg daily for 3 months may decrease subsequent infections by approximately 80% 5

Common Pitfalls and Caveats

• Penicillin alone is not effective for impetigo as it lacks adequate coverage against S. aureus 1
• Topical disinfectants are not useful in the treatment of impetigo 6
• Rising rates of bacterial resistance should inform treatment decisions 7
• Oral erythromycin was historically used but resistance rates are increasing 6, 8

Comparative Effectiveness

• Topical mupirocin has been shown to be as effective as oral erythromycin in the treatment of impetigo, with superior eradication of S. aureus, including antibiotic-resistant strains 9
• Mupirocin has a lower incidence of adverse effects compared to oral antibiotics 4, 9