What is the recommended treatment for a non-bullous impetigo patient?

Treatment of Non-Bullous Impetigo

Topical mupirocin 2% ointment applied three times daily for 5-7 days is the first-line treatment for localized non-bullous impetigo. 1, 2

Treatment Selection Based on Disease Extent

Localized Disease (First-Line)

• Mupirocin 2% ointment three times daily for 5-7 days is the preferred initial treatment as recommended by the Infectious Diseases Society of America and American College of Physicians 1, 2
• Retapamulin applied twice daily for 5 days serves as an alternative topical option if mupirocin is unavailable or not tolerated 1
• Topical therapy is preferred for limited disease because it produces fewer systemic side effects compared to oral antibiotics 2
• FDA data demonstrates 71% clinical efficacy for mupirocin versus 35% for placebo, with 94% pathogen eradication rates 3

Extensive Disease (Oral Antibiotics Required)

• Oral antibiotics should be used when impetigo involves numerous lesions, multiple body sites, or when topical therapy is impractical 1, 2

Oral Antibiotic Regimens

For Presumed Methicillin-Susceptible S. aureus (MSSA)

• Dicloxacillin 250 mg four times daily for adults for 7-10 days 1, 2
• Cephalexin 250-500 mg four times daily for adults for 7-10 days 1, 2
• Penicillin alone is NOT effective for impetigo because it lacks adequate coverage against S. aureus 2

For Suspected or Confirmed MRSA

• Clindamycin 300-450 mg three times daily for adults 1, 2
• This should be considered when MRSA is suspected based on local resistance patterns or treatment failure 2

Pediatric Dosing Adjustments

• Dicloxacillin: 12 mg/kg/day divided into 4 doses 1, 2
• Avoid tetracyclines (doxycycline, minocycline) in children under 8 years of age 1, 2
• Mupirocin demonstrated 78% clinical efficacy in pediatric patients aged 2 months to 15 years 3

Culture Guidance

• Gram stain and culture of pus or exudates are recommended to identify the causative organism, but treatment without cultures is reasonable in typical presentations 1
• Obtain cultures if there is treatment failure, MRSA is suspected, or in cases of recurrent infections 2

Infection Control Measures

• Keep lesions covered with clean, dry bandages to prevent spread 1, 2
• Maintain good personal hygiene with regular handwashing 1

Monitoring and Treatment Failure

• Re-evaluate the patient if there is no improvement after 48-72 hours of therapy 1, 2
• Consider alternative diagnosis if presentation is atypical or not responding to appropriate therapy 2

Special Population Considerations

• For pregnant patients, cephalexin is generally considered safe 2
• Avoid tetracyclines in pregnant women 1, 2

Important Clinical Pitfalls

• Rising resistance rates to erythromycin make macrolides less reliable empiric choices 4
• Topical disinfectants are inferior to antibiotics and should not be used 2, 4
• S. aureus has become the predominant pathogen (present in 80% of non-bullous impetigo), replacing group A streptococcus as the most common cause 5