Is it wrong to give oral steroids for ecthyma (impetigo)?

Oral Steroids Should Not Be Used for Ecthyma (Impetigo)

Oral steroids should absolutely not be used for ecthyma (impetigo) as they can worsen the infection and lead to potentially serious complications.

Understanding Ecthyma and Appropriate Treatment

Ecthyma is a deeper form of impetigo that extends into the dermis, presenting as vesicles that rupture and form circular, erythematous ulcers with adherent crusts and surrounding erythema 1. The condition is primarily caused by bacterial infection, most commonly Staphylococcus aureus, Streptococcus pyogenes, or both 2, 1.

Correct Treatment Approach:

• First-line treatment should be appropriate antibiotics, not steroids 2, 1
• For localized infections, topical antibiotics like mupirocin or fusidic acid are recommended 2, 3
• For more extensive infections, oral antibiotics are indicated:
  • Cephalexin (25-50 mg/kg/day divided into 4 doses for 7 days) for presumed methicillin-susceptible S. aureus 2
  • Clindamycin or sulfamethoxazole-trimethoprim when MRSA is suspected 2, 1
  • Penicillin for streptococcal infections in non-allergic patients 1

Why Steroids Are Contraindicated in Ecthyma

Harmful Effects of Steroids in Bacterial Skin Infections:

• Steroids suppress the immune response needed to fight bacterial infections 4
• They can mask symptoms while allowing the infection to worsen or spread 4
• Steroids may lead to more extensive infection and delayed healing 4
• Risk of developing more severe complications like bacteremia or sepsis 1

Evidence Against Steroid Use:

• No clinical guidelines recommend steroids for impetigo or ecthyma treatment 2, 1
• Steroids are specifically avoided in infectious conditions where they may worsen the underlying infection 4
• Topical steroids may cause perioral dermatitis and skin atrophy if used inadequately 4

Diagnostic Considerations

• Obtain cultures of the lesions to identify the causative organism and guide targeted therapy 1
• Gram stain and culture of pus are recommended to determine appropriate antibiotic selection 1
• Look for evidence of clinical infection such as crusting, erythema, and ulceration 4

Special Considerations

• Duration of antibiotic therapy should be 7-14 days for ecthyma 1
• In areas with high MRSA prevalence, empiric therapy should cover MRSA until culture results are available 2, 1
• Systemic antimicrobials should be used during outbreaks of poststreptococcal glomerulonephritis to eliminate nephritogenic strains 2, 1

Prevention of Spread

• Keep lesions covered with clean, dry bandages 2
• Practice good personal hygiene with regular handwashing 2
• Avoid sharing personal items that contact the skin 2

Remember that using oral steroids for ecthyma is not only ineffective but potentially dangerous, as it may suppress the immune response needed to fight the infection while allowing the bacteria to proliferate and potentially spread systemically 4, 1.