What is the recommended treatment for impetigo in children?

Treatment of Impetigo in Children

For limited impetigo in children, apply topical mupirocin 2% ointment three times daily for 5-7 days as first-line therapy; reserve oral antibiotics for extensive disease, multiple sites, or treatment failure. 1, 2

First-Line Treatment: Topical Antibiotics for Limited Disease

• Mupirocin 2% ointment applied three times daily for 5-7 days is the recommended first-line treatment for localized impetigo in children, as endorsed by the American Academy of Pediatrics and Infectious Diseases Society of America 1, 2, 3

• Retapamulin 1% ointment applied twice daily for 5 days is an effective alternative for limited disease 1, 2

• Topical antibiotics demonstrate superior cure rates compared to placebo (risk ratio 2.24) and are associated with fewer adverse effects than oral therapy 4

Second-Line Treatment: Oral Antibiotics for Extensive Disease

Oral antibiotics are indicated when:

• Impetigo involves multiple sites or extensive areas 1, 2
• Topical therapy is impractical (e.g., scalp involvement, numerous lesions) 1, 5
• Topical treatment has failed after 48-72 hours 2, 5
• Systemic symptoms are present 1, 2

Oral Antibiotic Selection (7-day course):

For Methicillin-Susceptible S. aureus (MSSA):

• Cephalexin (first-generation cephalosporin) or dicloxacillin, with weight-based dosing for children 1, 2
• Avoid penicillin alone—it lacks adequate S. aureus coverage and is inferior to other options 2, 5

For suspected Methicillin-Resistant S. aureus (MRSA):

• Clindamycin or trimethoprim-sulfamethoxazole are recommended 1, 2, 5
• Do not use doxycycline in children under 8 years of age due to tooth discoloration risk 2, 5

When to Consider MRSA Coverage

Empiric MRSA therapy should be considered in:

• Failure to respond to first-line therapy after 48-72 hours 1, 2
• High local prevalence of community-acquired MRSA 1, 2
• Residence in long-stay care facilities 2

Comparative Efficacy: Topical vs. Oral Therapy

• Topical mupirocin is slightly superior to oral erythromycin (risk ratio 1.07) in clinical trials 4
• No significant difference exists between topical antibiotics and other oral antibiotics for limited disease 4
• Topical therapy has fewer side effects, particularly gastrointestinal symptoms common with oral antibiotics 4

Critical Pitfalls to Avoid

• Never use topical disinfectants as primary therapy—they are inferior to antibiotics 2, 4
• Complete the full antibiotic course even if symptoms improve quickly to prevent complications like post-streptococcal glomerulonephritis 1
• Re-evaluate if no improvement occurs after 48-72 hours and consider culture for resistance patterns 2, 5
• Maintain good hygiene and keep lesions covered with clean, dry bandages to prevent spread 2, 5

Treatment Duration Summary

• Topical mupirocin: 5-7 days 1, 2
• Retapamulin: 5 days 1, 2
• Oral antibiotics: 7 days (some sources suggest 5-10 days for extensive disease) 2, 5