What is the treatment for impetigo in children?

Treatment of Impetigo in Children

For limited impetigo in children, topical mupirocin 2% ointment applied twice daily for 5 days is the first-line treatment, while extensive disease requires oral cephalexin (25-50 mg/kg/day divided into 4 doses) or dicloxacillin for 7 days. 1, 2, 3

Treatment Algorithm Based on Disease Extent

Limited Disease (Few Lesions)

• Topical mupirocin 2% ointment twice daily for 5 days is highly effective and superior to oral antibiotics for localized impetigo 1, 2, 4
• Topical retapamulin twice daily for 5 days is an alternative topical option 2
• Topical therapy achieves cure rates 6-fold higher than placebo and avoids systemic side effects 5, 4

Extensive Disease (Numerous Lesions or Outbreaks)

First-line oral antibiotics:

• Cephalexin syrup: 25-50 mg/kg/day divided into 4 doses for 7 days 2
• Dicloxacillin syrup: 25-50 mg/kg/day divided into 4 doses for 7 days 2
• Co-amoxiclav (amoxicillin-clavulanate) is an acceptable alternative providing coverage for both S. aureus and S. pyogenes 2, 6

When MRSA is suspected (based on local prevalence or treatment failure):

• Clindamycin syrup: 20-30 mg/kg/day divided into 3 doses for 7 days 1, 2
• Sulfamethoxazole-trimethoprim (SMX-TMP): 8-12 mg/kg/day (based on trimethoprim component) divided into 2 doses for 7 days 1, 2
• Doxycycline: 2-4 mg/kg/day divided into 2 doses for 7 days (only for children >8 years old) 1, 2

Critical Treatment Considerations

What NOT to Use

• Penicillin alone is seldom effective and should only be used when cultures confirm streptococci alone 1, 2
• Penicillin is inferior to erythromycin and cloxacillin with significantly worse cure rates 5, 4
• Amoxicillin alone lacks adequate coverage against S. aureus, which is now the predominant causative organism 2

Duration of Therapy

• Oral antibiotics require 7 days of treatment, not the shorter 5-day course used for topical agents 1, 2
• This distinction is critical to avoid treatment failure 2

Causative Organisms

• Bullous impetigo is caused exclusively by toxin-producing S. aureus 2, 7
• Non-bullous impetigo is caused by S. aureus, S. pyogenes, or both 2
• S. aureus typically colonizes the nose first before causing skin infection, while streptococci colonize damaged skin directly 1, 8

Special Populations and Precautions

Age-Related Restrictions

• Tetracyclines (doxycycline) must be avoided in children under 8 years due to risk of permanent dental staining 1, 2

High MRSA Prevalence Areas

• Empiric therapy should cover MRSA until culture results are available in areas with high community-acquired MRSA rates 1, 2, 7
• Local resistance patterns should guide antibiotic selection 8

When to Use Systemic Antibiotics During Outbreaks

• Systemic antimicrobials should be used during outbreaks of poststreptococcal glomerulonephritis to eliminate nephritogenic strains 2, 7

Comparative Efficacy Evidence

Topical vs. Oral Therapy

• Topical mupirocin is slightly superior to oral erythromycin (RR 1.07,95% CI 1.01-1.13) 4
• Topical antibiotics show better cure rates than placebo (RR 2.24,95% CI 1.61-3.13) 4
• Mupirocin and fusidic acid demonstrate equivalent efficacy (RR 1.03,95% CI 0.95-1.11) 5, 4

Side Effect Profile

• Oral antibiotics cause significantly more side effects than topical treatment, particularly gastrointestinal symptoms 5, 4
• The reported number of side effects overall is low, and most are mild 4

Infection Control Measures

To prevent spread and recurrence:

• Keep draining wounds covered with clean, dry bandages 1, 2
• Maintain good personal hygiene with regular handwashing using soap and water or alcohol-based hand gel 1, 2
• Avoid reusing or sharing personal items (razors, linens, towels) that contact infected skin 1
• Clean high-touch surfaces that contact bare skin (counters, doorknobs, bathtubs, toilet seats) 1

Common Pitfalls to Avoid

• Do not use disinfectant solutions as primary therapy—there is little evidence they improve impetigo outcomes 1, 4
• Do not prescribe oral antibiotics for limited disease when topical therapy is appropriate and more effective 2, 4
• Do not use rifampin as single agent or adjunctive therapy for impetigo 1
• Do not assume all impetigo is streptococcal—S. aureus is now the predominant pathogen 2, 8