Recurrent Impetigo Management
For a patient with three episodes of impetigo in six months, treat the acute infection with topical mupirocin 2% ointment three times daily for 5-7 days, then implement a decolonization strategy using intranasal mupirocin twice daily for 5 days combined with daily dilute bleach baths (1/4-1/2 cup per full bath) for 5 days to prevent further recurrences. 1, 2
Acute Episode Treatment
First-Line Therapy
Topical mupirocin 2% ointment applied three times daily for 5-7 days is the treatment of choice for localized impetigo, as it demonstrates superior efficacy with 71% clinical cure rates versus 35% for placebo and 94% pathogen eradication rates. 2, 3
Retapamulin 1% ointment twice daily for 5 days is an alternative topical option if mupirocin is unavailable or not tolerated. 2
Oral Antibiotics (For Extensive Disease)
Use oral antibiotics only when impetigo involves multiple body sites or when topical therapy is impractical. 2, 4
For methicillin-susceptible S. aureus (MSSA): dicloxacillin 250 mg four times daily or cephalexin 250-500 mg four times daily for 7 days. 2
For suspected or confirmed MRSA: clindamycin 300-450 mg three times daily or doxycycline for 7 days (avoid doxycycline in children under 8 years). 2, 4
Avoid penicillin alone as it lacks adequate S. aureus coverage and has demonstrated inferior cure rates compared to other antibiotics. 2, 4, 5
Decolonization Strategy for Recurrent Cases
Evidence-Based Approach
The recurrence pattern (3 episodes in 6 months) indicates likely S. aureus colonization requiring decolonization measures. 1
Implement a 5-day decolonization regimen combining intranasal mupirocin twice daily with daily bathing using dilute bleach solution (1/4-1/2 cup bleach per full bathtub of water). 1
Older studies showed that intranasal mupirocin for 5 days each month reduced recurrence rates, though efficacy data in the current MRSA era are limited. 1
Household and Environmental Measures
Extend decolonization measures to household contacts, as one study in children demonstrated significantly fewer recurrences when preventive measures included both patient and household contacts versus patient alone. 1
Implement daily washing of towels, sheets, combs, and razors during the decolonization period. 1
Use antibacterial hand cleanser regularly. 1
Alternative Decolonization Options
Monthly intranasal mupirocin (5 days per month) can be considered for ongoing suppression if recurrences continue despite initial decolonization. 1
A 3-month course of oral clindamycin 150 mg daily has shown benefit in older trials, though current efficacy against community-acquired MRSA is uncertain. 1
Critical Pitfalls to Avoid
Do not use topical disinfectants as primary therapy—they are inferior to antibiotics and lack supporting evidence. 2, 4, 6, 5
Do not rely on chlorhexidine-impregnated cloth scrubbing alone (three times weekly), as this approach was deemed ineffective in randomized trials. 1
Do not use intranasal mupirocin alone without bathing measures, as one military trial showed this single intervention did not reduce subsequent skin infections in MRSA carriers. 1
Avoid trimethoprim-sulfamethoxazole monotherapy unless streptococcal infection is definitively ruled out by culture, as it provides inadequate streptococcal coverage. 4
Monitoring and Follow-Up
Re-evaluate at 48-72 hours if no improvement occurs; consider MRSA coverage or alternative diagnosis. 2
Maintain good hygiene practices: keep lesions covered with clean, dry bandages to prevent spread. 2
If recurrences persist despite decolonization efforts, consider evaluation for underlying conditions such as neutrophil dysfunction, particularly if the patient has a history of recurrent infections since early childhood. 1
Consider obtaining cultures from active lesions during recurrent episodes to guide antibiotic selection and identify resistance patterns. 2