Impetigo is a highly contagious skin infection caused when bacteria enters damaged or broken skin and is most common in young children aged up to four years. In England and Wales, the incidence of impetigo in children aged 0 to 4 years is 84 per 100,000, and 54 per 100,000 in children aged 5 to 14
years[1] Show
Impetigo infection usually self-resolves within two to three weeks; however, with
effective treatment, infection should resolve in seven to ten days[2],[3] While impetigo generally affects the upper layer of the skin, secondary infections and complications (see below) can occur, which may be life-threatening if left
untreated[3] This article outlines the symptoms of active infection, appropriate management, prevention and when to refer. SymptomsTwo forms of impetigo exist: non-bullous (the most common
type) and bullous. Their main differences are summarised in Table 1 and can be seen in photoguides A and
B[2],[3],[4] Both
types begin with the appearance of multiple lesions; either small, red vesicles or sores that burst and dry to form yellow crusting. This may then extend and spread to other parts of the body. Redness varies with natural skin colour; therefore, in patients with darker skin pigmentation, sores with hyperpigmentation would be
seen[5],[6] Common infection sites include the face (e.g. around the nose and mouth), flexures, hands and limbs, but infection can also occur on other areas of the body, such as on the abdomen, buttocks and perineal
regions[3]
Photoguide: Non-bullous and bullous impetigo Source: Science Photo Library
A: Non-bullous impetigo lesions Causes and transmissionInfection occurs because of a break in the skin (e.g. a cut, scratch or insect bite) or an underlying skin condition (e.g. eczema, scabies, herpes simplex,
burns)[3] Staphylococcus aureus (S. aureus) is the most common causative organism for impetigo in the UK; however, Streptococcus pyogenes, which may co-exist with S. aureus
and methicillin-resistantS. aureus (MRSA), are also causative
agents[4],[7] Transmission occurs directly through close contact with an infected person (commonly via hands) or indirectly via contaminated objects (e.g. toys, clothes, towels). It has an incubation period of four to ten days; therefore, infection is often transmitted
unknowingly[4] Risk factorsHumid weather, crowded areas, poor hygiene and
pre-existing skin conditions (e.g. eczema) are risk factors for developing impetigo[4] Immunocompromised patients are more prone
to developing complications and if widespread infection is present then patients should be referred to secondary care based on clinical judgement [4] DiagnosisA formal diagnosis
is based solely on history and clinical appearance , with further questioning to rule out other conditions[4] Further investigations are usually not required unless the infection is recurrent, persistent or widespread.
If impetigo is recurrent, swabs for culture and sensitivity should be considered[2] Alternative diagnoses, such as herpes zoster infection (shingles), eczema, chickenpox or
molluscum contagiosum, should be considered in recurrent cases or those not responding to treatment[4],[10] ComplicationsInfection may progress to more serious complications, such as deep soft tissue infections (cellulitis or osteomyelitis), glomerulonephritis and
septicaemia[4] If the skin is red, hot and painful, then cellulitis should be suspected[11],[12] Staphylococcal scalded skin syndrome is a serious complication of impetigo, where a toxin released by Staphylococc us bacteria causes damage to the skin, resulting in painful extensive
blistering and the top layer of skin to peel off (see Figure 1)[3]
Figure 1: A baby aged two months with staphylococcal scalded skin syndrome Source: DermPics/Science Source/SCIENCE PHOTO LIBRARY Although impetigo will usually resolve without scarring, scarring
can occur; especially if the lesion is scratched, which should be advised against. Post-inflammatory hyperpigmentation may occur and is more common in those with darker skin
pigmentation[6] Guttate psoriasis is a self-limiting, non-infectious skin condition that may develop after an impetigo
infection[3] ManagementEffective management relies on ensuring that behaviours are adopted that help minimise the chance of spread and aid recovery, alongside pharmacotherapy to decrease recovery time or manage complications. Pharmacological managementManagement is typically completed with either topical or systemic therapy. Oral therapy is typically reserved for patients who show signs of systemic infection. Topical treatment Topical therapy should be used in localised non-bullous impetigo[2] Hydrogen peroxide 1% cream (applied two to three times daily for five days) is recommended by the National Institute for Health and Care Excellence (NICE) as the first-line treatment for non-complicated, non-bullous
impetigo[2] Fusidic acid 2% cream (applied three times daily for five days) may be used if hydrogen peroxide is ineffective or unsuitable
(e.g. if lesions are around the eyes)[2],[13] Mupirocin 2% cream (applied three times a day for five days) is recommended if fusidic acid resistance is suspected or
confirmed[4] For all three treatments, the duration may be extended to seven days if considered necessary in more widespread infection; however, topical fusidic acid should not be used for longer than ten
days to avoid the development of sensitisation and resistance[13] It is important to remind patients to wash their hands before and after applying cream or ointment, and to complete the course prescribed even after symptoms improve. Emphasise the need to continue using the treatment for the prescribed course, even if infection appears to have cleared. Systemic antibiotic treatment These are required with systemic infection; for example, patients with swollen lymph nodes and glands, fever and diarrhoea[4] An appropriate choice of oral antibiotics would be flucloxacillin, or a macrolide (e.g. clarithromycin or erythromycin)
in penicillin-allergic
patients[2],[4] If symptoms have not resolved, or have worsened, within seven days, then the patient should be reassessed to rule out differential diagnoses, as listed above. Any
recent antimicrobial therapy that the patient may have received should be considered before prescribing topical or oral antibiotic therapy. A combination of oral and topical antibiotics should be avoided because of the risk of development of
resistance[2] If the infection is recurrent and MRSA is identified following a nasal swab, advice should be sought from local microbiology as treatment will depend on local
resistance patterns[2] Non-pharmaceutical advicePatients and their parents/carers should be advised of hygiene measures that will aid healing and reduce the spread to other parts of the body, prevent secondary infection and reduce spread to others. Pharmacists should advise patients to:
Case studiesCase study 1: a five-year-old with a face rash A father comes into the pharmacy concerned about an itchy rash on his five-year-old’s face. On examination, you see that the child has small red sores about 1cm across around the mouth and nose and yellow crusting where these have burst. The father is worried that the child has chickenpox and asks whether it may be contagious to his child who is aeged 18 months. Due to the itchiness, crusting and location of the rash, non-bullous impetigo is suspected. Further questioning about duration and location reveals that the sores developed three days ago and are only present around this area. After asking why he suspected chickenpox, he explains that the child had chickenpox last year and thought he may have it again. You explain that this does not recur and once someone has chickenpox it does not return. Further questioning reveals that the child has no other conditions and is not immunocompromised. Supply fusidic acid 2% cream via the pharmacy’s Patient Group Direction (PGD). Explain to the patient to use this three times per day for five days, even if symptoms appear to clear. In addition, advise that the child should be kept out of school until 48 hours after first using the antibiotic cream. As to the father’s concerns around spreading of the infection, explain the importance of hand hygiene for the whole household, avoiding sharing towels or face cloths, cleaning toys with soap and water, and washing towels at a high temperature. The child’s nails should be cut short to avoid scratching of lesions. Advise that the child should be isolated from the younger sibling, where possible, while still infectious, and if the younger child develops similar symptoms, they will need to contact their GP for a prescription as they are under two years of age and not suitable for treatment under the PGD. Emphasise that even if there is some cream left from the first child’s infection, this should not be used as there is a risk of spreading the infection. Case study 2: a teenager presents with a dry, cracked rash A patient aged 15 years asks for advice for what they have described as a bad eczema flare. They have a background of Crohn’s disease, for which they are currently taking a reducing course of prednisolone following a recent flare. On examination, the infection appears to be characteristic of non-bullous impetigo owing to the appearance of red lesions with crusting. The skin is very dry and cracked, and you suspect that bacteria has entered broken skin and caused the infection. The infection is limited to this site and the surrounding area is not swollen or hot. The patient is otherwise well with no fever. The patient is immunosuppressed because of their corticosteroid use and, as such, is at high risk of complications. Therefore, referral to their GP for oral antibiotics treatment is appropriate, as per NICE
advice[2] Explain to the patient that eczema and the recent steroid course are risk factors for developing impetigo. Encourage them to discuss the management of their eczema with their GP to help manage flares and prevent future secondary infections. Advise the patient to keep eczema sites clean and well moisturised, particularly if taking steroids that may make them more susceptible to infection Case study 3: an infant has developed a rash after possible contact with a child with molluscum contagiosum A mother asks you to examine a rash her one-year-old has developed on her tummy a couple of days ago. A friend’s child was recently diagnosed with molluscum contagiosum and she thinks that this may be similar. While it may be possible that if the children had been in contact with each other, the virus may have been transmitted, but the presence of fluid-filled vesicles on the abdomen of the child, rather than in flexures, appears to be more likely a case of bullous impetigo. The characteristic dimple seen in molluscum contagiosum papules is not visible and some blisters have burst to form yellow crusting. This form of impetigo is more common in children aged under two years. Bullous impetigo should be treated with oral antibiotics. Refer the mother to the GP to prescribe antibiotics and rule out other differential diagnoses. Advise the mother to call the surgery and explain that impetigo is suspected because of its contagious nature. The GP will likely prescribe a five-day course of oral flucloxacillin liquid. As systemic infection is more common with this form of impetigo and can be serious in young children, advise the mother to look out for a raised temperature, cold and clammy skin, irritability or sleepiness. About the authors Preet Panesar is the lead antimicrobial pharmacist and Emily Green is a rotational pharmacist, both at University College London Foundation Hospitals. Contact: ; References[1] Elliot AJ, Cross KW, Smith GE et al. The association between impetigo, insect bites and air temperature: a retrospective 5-year study (1999–2003) using morbidity data collected from a sentinel general practice network database. Fam Pract 2006;23(5):490–496. doi: 10.1093/fampra/cml042 [2] National Institute for Health and Care Excellence. Impetigo: antimicrobial prescribing. NICE guideline [NG153]. 2020. Available at: https://www.nice.org.uk/guidance/ng153 (accessed September 2020) [3] NHS Inform. Impetigo. 2020. Available at: https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/impetigo (accessed September 2020) [4] National Institute for Health and Care Excellence. Impetigo. Clinical Knowledge Summary. 2020. Available at: https://cks.nice.org.uk/impetigo (accessed September 2020) [5] Vashi NA & Kundu RV. Facial hyperpigmentation: causes and treatment. Br J Dermatol 2013;169(S3):41–56. doi: 10.1111/bjd.12536 [6] Davis EC & Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. Clin Aesthet Dermatol 2010;3(7):20–31. PMID: 20725554 [7] Primary Care Dermatology Society. Impetigo. 2020. Available at: http://www.pcds.org.uk/clinical-guidance/impetigo (accessed September 2020) [8] Public Health Agency. Guidance on infection control in schools and other childcare settings. 2017. Available at: https://www.publichealth.hscni.net/sites/default/files/Guidance_on_infection_control_in%20schools_poster.pdf (accessed September 2020) [9] Public Health England. Health protection in schools and other childcare facilities. 2019. Available at: https://www.gov.uk/government/publications/health-protection-in-schools-and-other-childcare-facilities (accessed September 2020) [10] Sladden MJ & Johnston GA. Common skin infections in children. BMJ 2004;329:95–99. doi: 10.1136/bmj.329.7457.95 [11] NHS. Impetigo. 2018. Available at: https://www.nhs.uk/conditions/impetigo (accessed September 2020) [12] National Institute for Health and Care Excellence. Cellulitis – acute. Clinical Knowledge Summary. 2019. Available at: https://cks.nice.org.uk/topics/cellulitis-acute (accessed September 2020) [13] BMJ Group and Pharmaceutical Press. Joint Formulary Committee. British National Formulary (online). Available at: http://www.medicinescomplete.com (accessed September 2020) [14] Electronic medicines compendium. Naseptin nasal cream. 2017. Available at: https://www.medicines.org.uk/emc/product/5524/smpc#gref (accessed September 2020) Last updated 12 February 2021 19:07 CitationThe Pharmaceutical Journal, PJ September 2020, Vol 305, No 7941;305(7941):DOI:10.1211/PJ.2020.20208343Which side effects and adverse effects of mupirocin does a nurse teach a patient to monitor for while recieving therapy?Adverse Reactions/Side Effects
EENT: nasal only: cough, itching, pharyngitis, rhinitis, upper respiratory tract congestion. GI: nausea nasal only: altered taste. Derm: topical only: burning, itching, pain, stinging.
Which side effects will a nurse counsel a patient to monitor for while receiving griseofulvin?What side effects can this medication cause?. headache.. upset stomach.. vomiting.. diarrhea or loose stools.. thirst.. fatigue.. dizziness.. faintness.. Which antibiotic is used to treat acne vulgaris by acting on the dermal layer of the skin?Clindamycin 1% solution or gel is currently the preferred topical antibiotic for acne therapy. Topical erythromycin in 2% concentration is available as a cream, gel, lotion, or pledget,61, 62 but has reduced efficacy in comparison with clindamycin because of resistance of cutaneous Staphylococci and P acnes.
Which side effects would a nurse include when teaching a patient about the administration of Podofilox?Redness, itching, burning, and pain may occur in the treated area. If any of these effects persist or worsen, or if you have bleeding, severe swelling, or severe pain, wash the medication off with soap and water.
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