1. Polly Buchanan Community Dermatology Nurse Practitioner
Impetigo
Polly Buchanan
Community Dermatology Nurse Practitioner

2. 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

3. 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

4. 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

5. 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

6. 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

7. Non Bullous Impetigo

8. Non Bullous Impetigo

9. 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

10. 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

11. 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

12. 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

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

14. 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.

15. 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.

16. 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

17. 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

18. 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?

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

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

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

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

23. References