What is the recommended treatment for impetigo in children?

Treatment of Impetigo in Children

First-Line Treatment: Topical Therapy for Localized Disease

For children with localized, minor impetigo, mupirocin 2% topical ointment applied three times daily for 5-7 days is the recommended first-line treatment. 1, 2, 3

• Mupirocin is FDA-approved specifically for impetigo caused by Staphylococcus aureus and Streptococcus pyogenes, the two primary pathogens responsible for this infection 3
• The American Academy of Pediatrics and Infectious Diseases Society of America both endorse this as first-line therapy for superficial, localized lesions 1, 2
• Topical therapy achieves cure rates exceeding 90% when lesions are limited and superficial 4
• Retapamulin is an alternative topical agent if mupirocin is unavailable or has failed 5

When to Switch to Oral Antibiotics

Oral antibiotics are indicated when: 2

• Lesions are numerous or extensive
• Topical treatment is impractical
• Lesions involve the face, eyelids, or mouth
• No response to topical therapy after 3-5 days
• Systemic symptoms are present

Oral Antibiotic Regimens

For Methicillin-Susceptible S. aureus (MSSA)

First-line oral options include: 2, 5

• Dicloxacillin: 12 mg/kg/day divided into 4 doses for 7-10 days
• Cephalexin: 25 mg/kg/day divided into 4 doses for 7-10 days
• Amoxicillin-clavulanate: 25 mg/kg/day (of amoxicillin component) divided into 2 doses for 7-10 days

For Suspected or Confirmed MRSA

When MRSA is suspected (treatment failure, known local prevalence, or confirmed by culture): 1, 2, 5

• Clindamycin: 10-13 mg/kg/dose every 6-8 hours (total 40 mg/kg/day) if local resistance rate is <10%
• Trimethoprim-sulfamethoxazole (TMP-SMX): 8-12 mg/kg/day (based on trimethoprim component) divided into 2 doses
• Clindamycin provides dual coverage for both MRSA and streptococci 1

Critical Pitfalls to Avoid

Penicillin alone is NOT effective for impetigo because it lacks adequate coverage against S. aureus 2, 5

Tetracyclines (doxycycline, minocycline) are absolutely contraindicated in children under 8 years of age due to risk of permanent tooth discoloration 1, 2, 5

Macrolides (erythromycin) should be used with caution due to increasing resistance rates among S. aureus strains 5, 6

When to Obtain Cultures

Bacterial cultures are recommended in: 1, 2

• Treatment failure after 48-72 hours
• Suspected MRSA infection
• Recurrent infections
• Severe local infection or systemic illness

Treatment Algorithm

1. Assess extent of disease:

   • Limited, localized lesions → Mupirocin 2% ointment TID for 5-7 days 2, 3
   • Extensive lesions, facial involvement, or systemic symptoms → Oral antibiotics 2

2. If oral antibiotics needed:

   • Low MRSA prevalence area → Dicloxacillin or cephalexin for 7-10 days 2, 5
   • High MRSA prevalence or treatment failure → Clindamycin (if local resistance <10%) or TMP-SMX 1, 2

3. Reassess at 48-72 hours:

   • No improvement → Switch from topical to oral, or change oral agent based on culture results 2, 5
   • Consider MRSA coverage if not already initiated 5

Prevention and Hygiene Measures

To prevent spread and recurrence: 1, 2

• Cover draining wounds with clean, dry bandages
• Maintain good hand hygiene with soap and water or alcohol-based gel
• Avoid sharing personal items (razors, linens, towels)
• Clean high-touch surfaces regularly
• Evaluate and treat symptomatic household contacts 1

Special Considerations for Recurrent Impetigo

For children with recurrent infections: 5, 4

• Evaluate for nasal carriage of S. aureus
• Consider decolonization strategies after treating active infection
• Assess household contacts for colonization 1