What is the recommended treatment for a child diagnosed with impetigo?

Treatment of Impetigo in Children

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

First-Line Topical Therapy

• Mupirocin 2% ointment is the gold standard, applied to affected areas three times daily for 5-7 days, with clinical efficacy rates of 71-93% in controlled trials 3, 2
• Mupirocin is FDA-approved specifically for impetigo caused by Staphylococcus aureus and Streptococcus pyogenes 2
• Retapamulin 1% ointment twice daily for 5 days is an effective alternative if mupirocin is unavailable 3
• Keep draining wounds covered with clean, dry bandages to prevent spread 1, 3

When to Escalate to Oral Antibiotics

Escalate to systemic therapy if: 3

• No improvement after 48-72 hours of topical therapy
• Systemic symptoms present (fever, malaise, lymphadenopathy)
• Extensive disease involving multiple body sites
• Inability to apply topical therapy adequately

Oral Antibiotic Selection

For presumed methicillin-susceptible S. aureus (MSSA):

• Cephalexin 250-500 mg four times daily (adults) or weight-based dosing for children 3
• Dicloxacillin 250 mg four times daily (adults) or weight-based dosing for children 3

For suspected or confirmed MRSA:

• Clindamycin is the preferred option if local resistance rates are low (<10%) 1, 3
• Trimethoprim-sulfamethoxazole (TMP-SMX) is an alternative for MRSA coverage 1, 3

If coverage for both β-hemolytic streptococci and CA-MRSA is needed:

• Clindamycin alone provides dual coverage 1
• TMP-SMX combined with a β-lactam (e.g., amoxicillin) 1

Critical Age-Specific Restrictions

• Tetracyclines (doxycycline, minocycline) are absolutely contraindicated in children <8 years of age 1, 3
• For neonates and very young infants, refer to neonatal-specific dosing protocols as standard pediatric dosing is inappropriate 4

What NOT to Use

• Avoid penicillin alone - it lacks adequate coverage against S. aureus 3, 4
• Do not use bacitracin or neomycin - they are considerably less effective than mupirocin 3, 4
• Never use rifampin as monotherapy or adjunctive therapy for skin infections 1, 3
• Topical disinfectants are not useful for treating impetigo 5, 6

Special Considerations for Hospitalized Children

For hospitalized children with complicated skin infections requiring IV therapy: 1

• Vancomycin is recommended as first-line IV therapy
• Clindamycin 10-13 mg/kg/dose IV every 6-8 hours (40 mg/kg/day total) is an option if the patient is stable and local clindamycin resistance is <10%
• Linezolid 10 mg/kg/dose PO/IV every 8 hours for children <12 years; 600 mg twice daily for children ≥12 years

Duration of Therapy

• Topical therapy: 5-7 days 3, 2
• Oral therapy: 5-10 days, individualized based on clinical response 1
• If no improvement in 3-5 days, contact healthcare provider for reassessment 2

Hygiene and Prevention Measures

• Maintain good personal hygiene with regular bathing and handwashing with soap and water or alcohol-based gel 1
• Avoid reusing or sharing personal items (razors, linens, towels) that contacted infected skin 1
• Evaluate symptomatic household contacts for infection 1