What is the appropriate management of confirmed impetigo in a 1‑year‑old child?

Management of Impetigo in a 1-Year-Old Child

For confirmed impetigo in a 1-year-old, apply topical mupirocin 2% ointment three times daily for 5-7 days as first-line treatment for limited disease. 1, 2, 3

Treatment Algorithm

First-Line: Topical Antibiotic Therapy

• Mupirocin 2% ointment applied three times daily for 5-7 days is the recommended first-line treatment for limited impetigo (lesions covering up to 100 cm² total area) 1, 2, 3
• Before each application, gently wash the affected area with soap and water to remove crusts and enhance antibiotic penetration 2
• Topical mupirocin demonstrates superior efficacy compared to placebo (71% vs 35% clinical cure rates) and is as effective as oral erythromycin (93% vs 78.5% cure rates) in pediatric patients 3
• Retapamulin 1% ointment applied twice daily for 5 days is an effective alternative if mupirocin is unavailable or has failed 1, 4

When to Switch to Oral Antibiotics

Oral antibiotics are indicated when: 1, 2, 5

• Impetigo is extensive (multiple lesions across large body areas)
• Topical therapy is impractical
• No improvement after 48-72 hours of topical treatment
• Systemic symptoms develop (fever, malaise)

Oral Antibiotic Options for 1-Year-Old

For methicillin-susceptible S. aureus (MSSA): 1, 2

• Cephalexin (first-generation cephalosporin) - weight-based dosing
• Dicloxacillin - weight-based dosing
• Amoxicillin-clavulanate as an acceptable alternative

For suspected MRSA (treatment failure, high local prevalence): 1, 2

• Clindamycin - weight-based dosing
• Trimethoprim-sulfamethoxazole (TMP-SMX) - weight-based dosing
• Avoid doxycycline in children under 8 years of age 1, 4

Important caveat: Penicillin alone is NOT effective for impetigo as it lacks adequate coverage against S. aureus 1, 5

Infection Control Measures

• Keep the child home from daycare for at least 24 hours after initiating antibiotic treatment 2
• Trim fingernails short to reduce scratching and transmission 2
• Do not share towels, washcloths, clothing, or bedding with other household members 2
• Wash all clothing, towels, and bedding in hot water daily during the first few days of therapy 2
• Keep lesions covered with clean, dry bandages when possible to prevent spread 1, 2
• Examine siblings and close contacts for new lesions, as impetigo spreads easily within families 2

Follow-Up and Warning Signs

• Re-evaluate after 48-72 hours if no improvement is observed 1, 4
• Seek prompt evaluation if fever develops or worsens during treatment 2
• Watch for expansion of redness beyond original lesions or increasing pain, which suggests disease progression 2
• If impetigo is not responding to appropriate therapy, obtain cultures and consider alternative diagnoses or MRSA 1, 2

Common Pitfalls

• Topical antibiotics are superior to topical disinfectants - disinfectant solutions lack sufficient evidence and are inferior to antibiotic treatment 6
• Topical therapy shows fewer side effects compared to oral antibiotics, with gastrointestinal effects accounting for most oral antibiotic adverse events 6
• The increasing prevalence of community-acquired MRSA requires consideration of MRSA-active agents if first-line therapy fails 2, 7