Proper Documentation and Description of Impetigo in Clinical Assessment
When documenting impetigo in your clinical assessment, clearly specify whether it is nonbullous (70% of cases) or bullous (30% of cases), describe the characteristic lesion morphology, document the distribution and extent of involvement, and identify the likely causative organism based on clinical presentation.
Classification and Morphologic Description
Your documentation should begin by categorizing the impetigo type 1:
Nonbullous Impetigo (70% of cases)
- Causative organisms: Staphylococcus aureus, β-hemolytic streptococci, or both in combination 1
- Characteristic appearance: Erythematous papules that rapidly evolve into vesicles and pustules, which rupture to form honey-colored crusts on an erythematous base 1, 2
- Common locations: Face and extremities 3
Bullous Impetigo (30% of cases)
- Causative organism: Exclusively S. aureus strains producing exfoliative toxin 1
- Characteristic appearance: Fragile, thin-roofed vesicopustules that rupture, creating crusted, erythematous erosions, often surrounded by a collar of remnants from the blister roof 1
- Common locations: More likely to affect intertriginous areas 3
Essential Documentation Elements
Lesion Characteristics
Document the following specific features:
- Number of lesions: Distinguish between localized (<10 lesions, <36 cm² area) versus widespread disease 4
- Stage of evolution: Note whether lesions are in papular, vesicular, pustular, or crusted stages
- Distribution pattern: Specify anatomic locations (facial, perioral, extremities, intertriginous areas) 5
- Secondary infection: Document if impetigo is primary or secondarily infecting insect bites, eczema, or herpetic lesions 3
Associated Findings
Include in your assessment:
- Lymphadenopathy: Particularly cervical nodes in facial/perioral involvement 5
- Systemic signs: Temperature, presence/absence of SIRS criteria (fever >38°C or <36°C, tachypnea, tachycardia, WBC abnormalities) 1
- Pain and pruritus: Lesions are typically painless but may be slightly pruritic 5
Diagnostic Confirmation
Document whether cultures were obtained from vesicle fluid, pus, erosions, or ulcers to establish the causative organism 1. This is particularly important given:
- Rising methicillin-resistant S. aureus (MRSA) prevalence 3
- Macrolide-resistant streptococcus 3
- Mupirocin-resistant streptococcus 3
Differential Considerations
Your assessment should distinguish impetigo from:
- Ecthyma: A deeper infection with circular, erythematous ulcers with adherent crusts and surrounding erythematous edema that heals with scarring (unlike impetigo) 1
- Other vesiculobullous conditions requiring different management
Risk Factors to Document
Note relevant risk factors that influenced development 2:
- Disruptions to skin barrier
- Poor hygiene or crowded living environments
- Hot and humid climate exposure
- Malnutrition or diabetes
- Recent contact with infected individuals
Common Pitfalls to Avoid
- Don't assume penicillin coverage is adequate: Unless cultures yield streptococci alone, antimicrobial therapy should be active against both S. aureus and streptococci 1
- Don't overlook nasal carriage: In recurrent cases, document evaluation for S. aureus nasal carriage in patient and household contacts 6, 7
- Don't underestimate extent: Clearly quantify the number and distribution of lesions, as this determines whether topical versus systemic therapy is indicated 1, 2