Polly Buchanan Community Dermatology Nurse Practitioner Impetigo Polly Buchanan Community Dermatology Nurse Practitioner

Aetiology Pathogens Impetigo Staphylococcus aureus is the most common organism, Streptococcus pyogenes is the other pathogen involved, and on occasions both organisms can be found together. In warmer Bullous impetigo - is nearly always caused by Staphylococcus aureus Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of impetigo, and is associated more often with the non-bullous form Transmission passed on from an infected individual arise with no clear source of infection. Enters the skin at the site of a minor skin injury Secondary to another skin condition such as chickenpox Bullous impetigo - can affect intact skin

History Impetigo affects people of all races Impetigo can affect any age Non-bullous form is most common in children 2-5 years of age Bullous impetigo under the age of 2 years Males and females equally affected Impetigo is usually asymptomatic or mildly itchy

Clinical Findings Multiple lesions arise most commonly on exposed sites such as the face (particularly around the nose and mouth) and limbs, or in the flexures, especially the axillae Initial lesion is a thin-walled vesicle with an erythematous base (seldom observed) Golden yellow dried exudate or yellow-brown crusts. Thicker in streptococcal infections

Clinical Features Lesions extend gradually without central healing Lesions resolve without scaring within 2-3 weeks If there is an underlying skin condition such as eczema, lesions can become more widespread. ( ie develop secondary impetigo) Mucosal involvement is uncommon

Bullous Impetigo Small or large bullae arise over a short period of time, usually spreading locally on the face, trunk, extremities, buttocks, or perineal regions and may reach distal areas Bullae, which are less easily ruptured than in the non-bullous form, initially contain clear fluid, which then becomes cloudy. Once ruptured, brown-yellow crusts develop Unlike with the non-bullous form, extension occurs with central clearing The buccal mucous membrane can be involved

Non Bullous Impetigo

Non Bullous Impetigo

Investigations Impetigo is usually diagnosed on the basis of the clinical appearance Poorly responsive or recurrent cases of impetigo Refer to GP Lesions should be swabbed for C&S to identify possible methicillin-resistant Staphylococcus aureus (MRSA). Swabs are best taken from a moist lesion, or, in cases of bullous impetigo from a de-roofed blister

Management: Step 1 Step 1: General measures Provide a patient information leaflet on impetigo Cover affected areas where possible Wash hands regularly Use separate towels and flannels Avoid school until the lesions are healed or crusted over, or 48hours after antibiotics are started Anti-microbial topical treatments - Hydrogen Peroxide (Crystacide) , Benzoylkonium chloride, chlorhexidine products

Management: Step 2 Step 2: mild / local infections First-line treatment is topical Fusidic Acid 2% cream for 7-10 days Topical Fusidic Acid 2% cream bd In cases of Fusidic Acid resistance use topical Mupirocin

Management: Step 3 More widespread infection Use a systemic antibiotic for 7 days, either Flucloxacillin or Erythromycin / Clarithromycin. Reasons for choosing the latter include cases of penicillin allergy, or if there are concerns with regards to compliance

Complications Uncommon and most cases of impetigo settle fully within 2-3 weeks Streptococcal infection occasionally causes acute glomerulonephritis

Patient Group Direction – Fusidic Acid 2% Cream for Mild Localised Impetigo Inclusion Criteria: Adults and children aged 2 years or older with minor skin infection limited to a few lesions in one area of body. The rash consists of vesicles that weep and then dry to form yellow- brown crusts. Must obtain parental/guardian consent for treating a child under the age of 16 years. Patient must be present at consultation.

Patient Group Direction – Fusidic Acid 2% Cream for Mild Localised Impetigo Exclusion Criteria Multiple site skin infection. Children under the age of 2 years. Had impetigo within the last 3 months. Allergy to any component of the cream. Patient refuses treatment. Presenting with any underlying skin condition on the same area of the body as impetigo. Concerns with regarding patient compliance with topical medication.

Patient Group Direction – Fusidic Acid 2% Cream for Mild Localised Impetigo Caution/ Need for further advice: Uncertain diagnosis Impetiginised eczema Eczema Herpeticum Action if Patient declines or is excluded: Refer patient to GP or OOHs for review

Fusidic Acid 2% Cream Legal Status: POM Route/ Method: Topical Dosage: Apply to lesions Four times daily for 7 days. Frequency: Apply Four times daily Duration of treatment Maximum treatment 7 days. Maximum or minimum treatment period: maximum of 7 days. Maximum of one supply in three months Quantity to Supply: 1 x 15gm tube

Case History 1 3 year old child Lesions on chin developed over 2 days Erythema++ Vesicles+++ Golden crusts+++ Not painful or itchy Diagnosis? Management & Advice?

Case History 2 68 year old man History of Atopic Eczema Dry skin+++ Lichenification+++ Erythema++ Itch+++ Erosions+++ Golden crusting +/- Excoriations+++ Diagnosis? Management & Advice?

Case History 3 29 year old male Pain and tingling sensation+++ (before appearance of lesions) Erythema++ Vesicles++ Erosions++ Crusting+ Diagnosis? Management and Advice?

Eczema Herpeticum Rare Very Serious Patient Unwell +++ Urgent referral Antiviral medication

Case Study 4 11 month old child Lesions appeared over 2-3 days Erythema++ Vesicles++ Crusts++ Erosions+ No itch Diagnosis? Management and Advice?

References http://www.pcds.org.uk/