What is the treatment for oral impetigo?

Treatment of Oral Impetigo

For impetigo involving the mouth or oral area, oral antibiotics are required rather than topical therapy, with cephalexin or dicloxacillin as first-line agents for 7 days, switching to clindamycin or trimethoprim-sulfamethoxazole if MRSA is suspected. 1

Why Oral Antibiotics Are Mandatory for Oral Lesions

• Lesions on the face, eyelid, or mouth require oral antibiotics because topical agents cannot be effectively applied to these areas 1
• Topical mupirocin, while highly effective for impetigo on other body sites, is impractical for oral lesions due to location and moisture 1, 2

First-Line Oral Antibiotic Regimens

For Presumed Methicillin-Susceptible S. aureus (MSSA)

• Cephalexin 250-500 mg four times daily for adults (25-50 mg/kg/day divided into 4 doses for children) for 7 days 3, 1, 4
• Dicloxacillin 250 mg four times daily for adults (25-50 mg/kg/day divided into 4 doses for children) for 7 days 3, 1, 4
• Both agents provide excellent coverage against S. aureus and S. pyogenes, the two primary pathogens in impetigo 3, 5

For Suspected or Confirmed MRSA

• Clindamycin 300-450 mg three times daily for adults (20-30 mg/kg/day divided into 3 doses for children) for 7 days 3, 1, 4
• Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily for adults (8-12 mg/kg/day based on trimethoprim component, divided into 2 doses for children) for 7 days 3, 1, 4
• Doxycycline 2-4 mg/kg/day divided into 2 doses for 7 days (only for children over 8 years old due to dental staining risk) 1, 4

Critical Treatment Considerations

What NOT to Use

• Penicillin alone is not effective for impetigo because it lacks adequate coverage against S. aureus, which is the predominant pathogen 1, 5
• Bacitracin and neomycin are considerably less effective and should not be used 1

When to Obtain Cultures

• Obtain cultures from lesions if there is treatment failure, MRSA is suspected, or in cases of recurrent infections 1
• In areas with high MRSA prevalence, empiric therapy should cover MRSA until culture results are available 4

Duration of Therapy

• The standard duration is 7 days for oral antibiotic therapy 3, 1, 4
• Some guidelines suggest 5-10 days is acceptable, but 7 days represents the consensus recommendation 1

Special Populations and Precautions

Penicillin-Allergic Patients

• Clindamycin is the preferred alternative for penicillin-allergic patients 1
• Cephalexin can be used with caution in patients without type 1 hypersensitivity reactions 4

Pregnant Patients

• Cephalexin is considered a safe alternative for pregnant patients 1, 4

Children Under 8 Years

• Avoid tetracyclines (doxycycline) in children under 8 years due to risk of permanent dental staining 1, 4

Prevention of Spread

• Keep lesions covered with clean, dry bandages to prevent transmission 1, 4
• Maintain good personal hygiene with regular handwashing 1, 4
• Avoid sharing personal items that contact the skin such as towels, washcloths, or eating utensils 1, 4

Common Pitfalls to Avoid

• Do not use topical therapy for oral/perioral impetigo—it will fail due to poor adherence and moisture 1
• Do not prescribe penicillin monotherapy—it lacks S. aureus coverage and has inferior cure rates compared to other oral antibiotics 3, 1, 5
• Do not assume all impetigo is MSSA—consider local resistance patterns and obtain cultures when MRSA is suspected 1, 4
• Do not use disinfectant solutions as primary therapy—they are inferior to antibiotics 1, 6