What is the most likely diagnosis and appropriate management for honey‑coloured crusted lesions around the lips of a 6‑year‑old child?

Impetigo: Diagnosis and Management in a 6-Year-Old

The honey-colored crusted lesions around the lips in this 6-year-old child are diagnostic of nonbullous impetigo, and treatment should begin with topical mupirocin or retapamulin applied three times daily for 5 days.

Clinical Diagnosis

The presentation is pathognomonic for nonbullous impetigo, which accounts for 70% of impetigo cases and is characterized by honey-colored crusts on the face and extremities 1, 2. This is the most common bacterial skin infection in children aged 2-5 years 1. The perioral location is typical, as facial involvement is characteristic of nonbullous impetigo 1.

• Causative organisms: Staphylococcus aureus and/or Streptococcus pyogenes 1, 3
• Clinical course: Self-limited, typically resolving within 2-3 weeks without scarring 1
• Diagnosis: Based on clinical presentation; culture is not routinely needed 2

Treatment Algorithm

First-Line: Topical Antibiotics

For limited impetigo (as in this case), topical therapy is preferred and as effective as—if not more effective than—systemic antibiotics 4.

Topical options:

• Mupirocin 2% ointment: Apply three times daily for 5 days 1, 3, 5
• Retapamulin 1% ointment (ALTABAX): Apply twice daily for 5 days 6, 1, 3
  • FDA-approved for children ≥9 months 6
  • Clinical success rate of 85.6% vs 52.1% for placebo 6
  • Covers both methicillin-susceptible S. aureus (89.8% success) and S. pyogenes (90.6% success) 6

When to Use Oral Antibiotics

Oral antibiotics should be reserved for 1, 3:

• Multiple lesions
• Household outbreaks
• Impractical topical therapy
• Large bullae (though this case is nonbullous)

Oral antibiotic options (if needed):

• First-line: Cephalexin or dicloxacillin 1, 3
• Alternative: Amoxicillin-clavulanate (80 mg/kg/day) 1, 5
• If MRSA suspected: Clindamycin or trimethoprim-sulfamethoxazole 1, 3, 4
• Avoid: Penicillin alone (inadequate coverage) 1

Critical Management Points

Wound Care

• Gently remove crusts with warm saline-soaked gauze before applying topical antibiotics 7
• Apply petroleum-based ointment (white soft paraffin) every 2 hours to prevent drying and cracking 7, 8
• Maintain oral hygiene with soft toothbrush and mild fluoride toothpaste 7, 8
• Warm saline mouth rinses daily 7, 8

Dietary Modifications

• Avoid irritants: Spicy foods, hot beverages, and citrus fruits delay healing 7, 8
• Offer soft, bland foods at room temperature 7
• Ensure adequate hydration, as painful lip lesions may cause children to resist drinking 7

Infection Control

• Avoid sharing towels, washcloths, or eating utensils to prevent household spread 1
• Keep fingernails short to minimize autoinoculation 1
• Exclude from school/daycare until 24 hours after starting antibiotics 1

Common Pitfalls to Avoid

1. Do not use topical disinfectants—they are inferior to antibiotics 1
2. Avoid topical anesthetics (e.g., lidocaine) on perioral lesions due to risk of accidental ingestion and systemic toxicity in young children 7
3. Do not prescribe penicillin alone—it lacks adequate S. aureus coverage 1
4. Consider MRSA coverage if the infection fails to improve with initial therapy 3, 4

Monitoring and Follow-Up

• Expected improvement: Within 2-3 days of starting treatment 1
• Complete resolution: Within 2-3 weeks 1
• Complications are rare but include poststreptococcal glomerulonephritis (monitor for hematuria, edema, hypertension if symptoms develop) 1
• Recurrence: If recurrent impetigo occurs, consider nasal carriage of S. aureus and decolonization with intranasal mupirocin 4

Antibiotic Resistance Considerations

Rising rates of methicillin-resistant S. aureus (MRSA), macrolide-resistant streptococcus, and mupirocin-resistant streptococcus should inform treatment decisions 1, 4. If the patient fails to respond to first-line topical therapy within 3-5 days, consider culture and switch to clindamycin or trimethoprim-sulfamethoxazole for MRSA coverage 3, 4.