What is the recommended management for impetigo in children, including topical and oral antibiotic options?

Management of Impetigo in Children

First-Line Treatment: Topical Antibiotics for Limited Disease

For children with limited impetigo (lesions covering up to 100 cm² total area), apply topical mupirocin 2% ointment three times daily for 5-7 days as first-line therapy. 1, 2

• Before applying mupirocin, gently wash the affected area with soap and water to remove crusts and enhance antibiotic penetration. 1
• Retapamulin 1% ointment applied twice daily for 5 days is an acceptable alternative for children aged 9 months or older. 1, 3
• Topical antibiotics achieve cure rates 6-fold higher than placebo and are superior to oral antibiotics for limited disease. 3, 4

Second-Line Treatment: Oral Antibiotics for Extensive Disease

Oral antibiotics are indicated when impetigo is extensive (multiple sites), topical therapy is impractical, topical treatment has failed after 48-72 hours, or systemic symptoms are present. 1, 2

For Presumed Methicillin-Susceptible S. aureus (MSSA):

• Cephalexin 25-50 mg/kg/day divided into 4 doses for 7 days is the preferred first-line oral antibiotic. 3
• Dicloxacillin 25-50 mg/kg/day divided into 4 doses for 7 days is an equally effective alternative. 3
• Amoxicillin-clavulanate is acceptable when the above agents are not suitable. 1, 3

For Suspected or Confirmed MRSA:

Consider MRSA coverage in patients who fail first-line therapy, reside in long-stay care facilities, or live in areas with high MRSA prevalence. 1, 2

• Clindamycin 20-30 mg/kg/day divided into 3 doses for 7 days is recommended. 3
• Trimethoprim-sulfamethoxazole 8-12 mg/kg/day (based on trimethoprim component) divided into 2 doses for 7 days is an alternative. 3
• Doxycycline 2-4 mg/kg/day divided into 2 doses for 7 days may be used only in children over 8 years old due to risk of permanent dental staining. 3

Critical Pitfalls to Avoid

• Never prescribe penicillin or amoxicillin alone for impetigo—these lack adequate coverage against S. aureus, which is now the predominant causative organism. 2, 3
• Do not use cefdinir when MRSA is suspected, documented, or confirmed. 3
• Topical disinfectants are inferior to antibiotics and should not be used as primary therapy. 2, 5
• Oral antibiotics require a full 7-day course, not the shorter 5-day duration used for topical agents. 2, 3

Infection Control Measures

Keep the child home from school, daycare, and organized sports until at least 24 hours after initiating antibiotic treatment. 1

• Keep fingernails trimmed short to reduce scratching and transmission. 1
• Encourage frequent handwashing with soap and water, especially after touching lesions. 1
• Do not share towels, washcloths, clothing, or bedding with other household members. 1
• Wash all clothing, towels, and bedding in hot water daily during the first few days of therapy. 1
• Keep lesions covered with clean, dry bandages to prevent spread. 2, 3
• Avoid close-contact sports and swimming pools until lesions are fully healed and no longer draining. 1

Monitoring and Follow-Up

Re-evaluate the child if no improvement occurs after 48-72 hours of therapy. 2

• Development or worsening of fever during treatment may indicate complications such as cellulitis or systemic infection. 1
• Expansion of redness beyond the original lesions or increasing pain suggests disease progression requiring reassessment. 1
• Examine siblings and close household contacts for new lesions, as impetigo spreads easily within families. 1

Special Considerations

• During outbreaks of poststreptococcal glomerulonephritis, systemic antimicrobials should be used to eliminate nephritogenic strains. 3
• Complete the full course of prescribed antibiotics even if symptoms improve quickly to prevent complications. 1
• Patients with diabetes or immunosuppression may require a lower threshold for systemic antibiotics and hospital admission if extensive disease or systemic signs are present. 3