What is the appropriate treatment for impetigo affecting the eyelid or peri‑ocular skin?

Treatment of Impetigo Near the Eye

For impetigo affecting the eyelid or peri-ocular skin, use topical mupirocin 2% ointment applied three times daily for 5-7 days as first-line therapy, with careful application to avoid direct contact with the eye itself. 1, 2

Initial Assessment

• Examine the extent of involvement: if lesions are limited to the eyelid margins and immediately surrounding skin, topical therapy is appropriate 1
• Check for systemic signs or extensive disease beyond the periocular area, which would necessitate oral antibiotics 1
• Assess local MRSA prevalence patterns, as this influences empiric coverage decisions 1

First-Line Topical Treatment

• Mupirocin 2% ointment is FDA-approved for impetigo caused by Staphylococcus aureus and Streptococcus pyogenes, applied three times daily for 5-7 days 2, 3
• Apply the ointment carefully to the affected eyelid skin without getting it directly into the eye, though the petrolatum base is similar to ophthalmic formulations 1
• Topical antibiotics (mupirocin, retapamulin, fusidic acid) are effective and may be superior to oral antibiotics for localized disease 3, 4

Essential Eyelid Hygiene Measures

• Apply warm compresses to the eyelids for several minutes before medication to soften honey-colored crusts and improve antibiotic penetration 1
• Gently cleanse eyelid margins using diluted baby shampoo or commercial eyelid cleaners on a cotton swab to remove crusts 1
• Consider hypochlorous acid 0.01% eyelid cleaners as adjunctive antimicrobial therapy 1

When to Use Oral Antibiotics

Switch to oral therapy if: 1

• The infection extends extensively beyond the eyelid margins
• Multiple lesions make topical application impractical
• MRSA is suspected based on local prevalence
• No improvement after 48-72 hours of topical therapy

Oral Antibiotic Options:

For presumed methicillin-susceptible S. aureus: 1

• Cephalexin 25-50 mg/kg/day divided into 4 doses for 7 days (first-line)

For suspected MRSA: 1

• Clindamycin 20-30 mg/kg/day divided into 3 doses for 7 days
• Trimethoprim-sulfamethoxazole 8-12 mg/kg/day (based on trimethoprim) divided into 2 doses for 7 days

Critical Periocular Precautions

• Use gentle application technique without aggressive rubbing on the delicate eyelid skin 1
• Keep lesions covered with clean, dry bandages when feasible to prevent autoinoculation to other facial areas 1
• Emphasize strict hand hygiene after touching the affected eyelid to prevent spread 1

Common Pitfalls to Avoid

• Do not use topical disinfectants—they are inferior to antibiotics and not recommended 3, 4
• Avoid penicillin V as it is seldom effective for impetigo 3, 4
• Do not use trimethoprim-sulfamethoxazole as monotherapy without ruling out streptococcal infection, as it provides inadequate streptococcal coverage 3
• Be aware that macrolide resistance (erythromycin) is rising and mupirocin-resistant strains are documented 3, 4

Expected Course and Follow-Up

• Impetigo typically resolves within 2-3 weeks without scarring, though treatment shortens the clinical course 3, 5
• Reassess at 48-72 hours: if no improvement, consider MRSA coverage or oral therapy 1
• Complications are rare, with poststreptococcal glomerulonephritis being the most serious potential sequela 3