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Impetigo is a highly contagious infection most common in children aged 2–5 years.
What will the patient tell you? (History)
What will the patient tell you? (History)
Patients or caregivers will typically report:
The presence of lesions that may be itchy or mildly painful.
The lesions often begin as small red spots or blisters at a site of minor skin injury, particularly around the mouth, nose, arms, or legs.
Rapid spreading of lesions or the development of new "satellite" spots.
Systemic symptoms like fever and malaise are rare; their presence suggests bullous impetigo or secondary infection.
A history of skin barrier disruption is common, such as insect bites, eczema, abrasions, or chickenpox.
Epidemiology and Risk Factors:
The infection spreads easily through direct contact, especially in crowded settings or areas with poor hygiene. Predisposing factors include:
Underlying skin conditions (e.g., eczema, contact dermatitis).
Hot, humid environments.
Immunosuppression.
What will it look like? (Examination)
Impetigo is a superficial infection presenting in three forms. It's often highly clustered and contagious. Regional lymphadenopathy (swollen lymph nodes) may be present.
Non-bullous Impetigo ("School Sores"):
Starts as a small, red macule that quickly evolves into a thin-walled vesicle or pustule.
The characteristic feature is the ruptured lesion, which leaves a thick, sticky, honey-coloured crust with minimal surrounding redness.
Commonly found on the face (around the nose and mouth) and extremities.
Bullous Impetigo:
Presents as flaccid bullae (blisters) containing clear or yellow fluid, typically on the trunk, buttocks, or perineum.
The bullae rupture easily, leaving a raw, red base with a rim of scale (collarette of scale).
Ecthyma:
A deeper, ulcerative form characterized by punched-out lesions with thick, brown-black crusts. This form has the potential to cause scarring.
Key Considerations in Darker Skin Tones
The honey-coloured crust remains the most reliable diagnostic sign.
Erythema (redness) may be less visible and can present as darker brown, violaceous, or greyish tones in early lesions.
After healing, post-inflammatory hyperpigmentation or hypopigmentation is more prominent and persistent.
How can you help? (Treatment)
Impetigo is highly treatable, typically resolving within 7–10 days with therapy.
General Measures:
Hygiene: Gently remove crusts using warm, soapy water to allow the treatment to penetrate. Encourage frequent handwashing, keep nails short, and cover lesions with watertight dressings to prevent spread.
Exclusion: Children should be excluded from school/nursery until the lesions are crusted over or until they have received 24 hours of antibiotic therapy.
Topical Treatment (For localized non-bullous impetigo):
Antiseptic Therapy: Often the first-line approach to limit antibiotic resistance (e.g., Hydrogen peroxide 1% cream or povidone-iodine 10% ointment, applied 2–3 times daily for 5–7 days).
Topical Antibiotics: Fusidic acid is common. Mupirocin should be reserved for cases where MRSA is suspected.
Oral Antibiotics: Required for: Bullous impetigo, widespread lesions (more than 3), systemic symptoms, or failure of topical treatment.
First-line: Flucloxacillin (covers S. aureus and S. pyogenes).
Alternatives (Penicillin Allergy): Erythromycin or clarithromycin.
Alternatives (Broad Spectrum): Cephalexin or Amoxicillin–clavulanate.
Management of Recurrent Cases:
Swab the lesions and the nares (nostrils) to check for staphylococcal nasal carriage.
If nasal carriage is confirmed, use mupirocin nasal ointment to eliminate the reservoir.
Assess for and manage underlying conditions like eczema.
Complications: Though rare, serious complications include Cellulitis and Post-streptococcal glomerulonephritis (a kidney complication that occurs 1–2 weeks after infection). Post-inflammatory pigmentation is common in darker skin tones.
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