Guidance

Recommendations

Recommendations

1.1 Managing impetigo

Advice to reduce the spread of impetigo

1.1.1

Advise people with impetigo, and their parents or carers if appropriate, about good hygiene measures to reduce the spread of impetigo to other areas of the body and to other people.

For a short explanation of why the committee made the recommendation, see the rationale section on advice to reduce the spread of impetigo.

Full details of the evidence and the committee's discussion are in evidence review.

Initial treatment

Localised non-bullous impetigo
1.1.2

Consider hydrogen peroxide 1% cream for people with localised non-bullous impetigo who are not systemically unwell or at high risk of complications (see recommendations on choice of antimicrobial). Although other topical antiseptics are available for treating superficial skin infections, no evidence was found for using them to treat impetigo.

1.1.3

If hydrogen peroxide 1% cream is unsuitable, offer a short course of a topical antibiotic for people with localised non-bullous impetigo who are not systemically unwell or at high risk of complications (see recommendations on choice of antimicrobial).

Widespread non-bullous impetigo
1.1.4

Offer a short course of a topical or oral antibiotic for people with widespread non‑bullous impetigo who are not systemically unwell or at high risk of complications (see recommendations on choice of antimicrobial). Take into account:

  • that topical and oral antibiotics are both effective at treating impetigo

  • the preferences of the person and, if appropriate, their parents or carers, including the practicalities of administration (particularly to large areas) and possible adverse effects

  • previous use of topical antibiotics because antimicrobial resistance can develop rapidly with extended or repeated use.

Bullous impetigo or impetigo in people who are systemically unwell or at high risk of complications
Combination treatment
1.1.6

Do not offer combination treatment with a topical and oral antibiotic to treat impetigo.

For a short explanation of why the committee made these recommendations, see the rationale section on initial treatment.

Full details of the evidence and the committee's discussion are in evidence review.

Advice on treatment

1.1.7

Advise people with impetigo, and their parents or carers if appropriate, to seek medical help if symptoms worsen rapidly or significantly at any time, or have not improved after completing a course of treatment.

Reassessment and further treatment

1.1.8

Reassess people with impetigo if their symptoms worsen rapidly or significantly at any time or have not improved after completing a course of treatment.

1.1.9

When reassessing people with impetigo, take account of:

  • other possible diagnoses, such as herpes simplex

  • any symptoms or signs suggesting a more serious illness or condition, such as cellulitis

  • previous antibiotic use, which may have led to resistant bacteria.

1.1.10

For people with impetigo that is worsening or has not improved after treatment with hydrogen peroxide 1% cream, offer:

1.1.11

For people with impetigo that is worsening or has not improved after completing a course of topical antibiotics:

1.1.12

For people with impetigo that is worsening or has not improved after completing a course of oral antibiotics, consider sending a skin swab for microbiological testing.

1.1.13

For people with impetigo that recurs frequently:

  • send a skin swab for microbiological testing and

  • consider taking a nasal swab and starting treatment for decolonisation.

1.1.14

If a skin swab has been sent for microbiological testing:

  • review the choice of antibiotic when results are available and

  • change the antibiotic according to results if symptoms are not improving, using a narrow-spectrum antibiotic if possible.

For a short explanation of why the committee made these recommendations, see the rationale section on reassessment and further treatment for impetigo.

Full details of the evidence and the committee's discussion are in evidence review.

Referral and seeking specialist advice

1.1.15

Refer to hospital:

  • people with impetigo and any symptoms or signs suggesting a more serious illness or condition (for example, cellulitis)

  • people with widespread impetigo who are immunocompromised.

1.1.16

Consider referral or seeking specialist advice for people with impetigo if they:

  • have bullous impetigo, particularly in babies (aged 1 year and under)

  • have impetigo that recurs frequently

  • are systemically unwell

  • are at high risk of complications.

For a short explanation of why the committee made these recommendations, see the rationale section on referral and seeking specialist advice for impetigo.

Full details of the evidence and the committee's discussion are in evidence review.

1.2 Choice of antimicrobial

1.2.1

When prescribing an antimicrobial for impetigo, take account of local antimicrobial resistance data when available and follow:

  • Table 1 for adults aged 18 years and over

  • Table 2 for children and young people under 18 years.

Table 1 Antimicrobials for adults aged 18 years and over
Treatment Antimicrobial, dosage and course length

Topical antiseptic

Hydrogen peroxide 1%:

Apply two or three times a day for 5 days

First-choice topical antibiotic if hydrogen peroxide is unsuitable (for example, if impetigo is around eyes) or ineffective

Fusidic acid 2%:

Apply three times a day for 5 days

Alternative topical antibiotic if fusidic acid resistance is suspected or confirmed

Mupirocin 2%:

Apply three times a day for 5 days

First-choice oral antibiotic

Flucloxacillin:

500 mg four times a day for 5 days

Alternative oral antibiotic for penicillin allergy or if flucloxacillin is unsuitable (for people who are not pregnant)

Clarithromycin:

250 mg twice a day for 5 days (the dosage can be increased to 500 mg twice a day, if needed for severe infections)

Alternative oral antibiotic for penicillin allergy in pregnancy

Erythromycin:

250 mg to 500 mg four times a day for 5 days

Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.

If meticillin-resistant Staphylococcus aureus is suspected or confirmed

Consult a local microbiologist

See the BNF for appropriate use and dosing in specific populations, for example, in people with hepatic or renal impairment, and in pregnancy and breastfeeding.

A 5‑day course is usually appropriate but can be increased to 7 days based on clinical judgement, depending on the severity and number of lesions.

Other topical antiseptics besides hydrogen peroxide are available for superficial skin infections, but no evidence was found for these in impetigo

As with all antibiotics, extended or recurrent use of topical fusidic acid or mupirocin may increase the risk of developing antimicrobial resistance. See the BNF for more information.

Table 2 Antimicrobials for children and young people under 18 years
Treatment Antimicrobial, dosage and course length

Topical antiseptic

Hydrogen peroxide 1%:

Apply two or three times a day for 5 days

First-choice topical antibiotic if hydrogen peroxide is unsuitable (for example, if impetigo is around eyes) or ineffective

Fusidic acid 2%:

Apply three times a day for 5 days

Alternative topical antibiotic if fusidic acid resistance is suspected or confirmed

Mupirocin 2%:

Apply three times a day for 5 days

First-choice oral antibiotic

Flucloxacillin (oral solution or capsules):

1 month to 1 year, 62.5 mg to 125 mg four times a day for 5 days

2 years to 9 years, 125 mg to 250 mg four times a day for 5 days

10 years to 17 years, 250 mg to 500 mg four times a day for 5 days

Alternative oral antibiotic for penicillin allergy or if flucloxacillin is unsuitable (for people who are not pregnant; for example, if an oral solution is unpalatable and the child is unable to swallow capsules)

Clarithromycin:

1 month to 11 years:

under 8 kg, 7.5 mg/kg twice a day for 5 days

8 kg to 11 kg, 62.5 mg twice a day for 5 days

12 kg to 19 kg, 125 mg twice a day for 5 days

20 kg to 29 kg, 187.5 mg twice a day for 5 days

30 kg to 40 kg, 250 mg twice a day for 5 days

12 years to 17 years, 250 mg twice a day for 5 days (the dosage can be increased to 500 mg twice a day, if needed for severe infections)

Alternative oral antibiotic for penicillin allergy in pregnancy

Erythromycin:

8 years to 17 years, 250 mg to 500 mg four times a day for 5 days

Erythromycin is preferred if a macrolide is needed in pregnancy, for example, if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms. See the Medicines and Healthcare products Regulatory Agency (MHRA) Public Assessment Report on the safety of macrolide antibiotics in pregnancy.

If meticillin-resistant Staphylococcus aureus is suspected or confirmed

Consult a local microbiologist

See the BNF for Children for appropriate use and dosing in specific populations, for example, in people with hepatic or renal impairment, and in pregnancy and breastfeeding. Dosing in some age groups may be off-label.

The age bands apply to children of average size and, in practice, the prescriber will use the age bands with other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age.

A 5‑day course is usually appropriate but can be increased to 7 days based on clinical judgement, depending on the severity and number of lesions.

Other topical antiseptics besides hydrogen peroxide are available for superficial skin infections, but no evidence was found for these in impetigo.

Licenses for mupirocin use in infants vary between products. See individual summaries of product characteristics for details.

As with all antibiotics, extended or recurrent use of topical fusidic acid or mupirocin may increase the risk of developing antimicrobial resistance. See the BNF for Children for more information.

If flucloxacillin oral solution is not tolerated because of poor palatability, consider capsules (see the Medicines for Children leaflet on helping your child to swallow tablets).

For a short explanation of why the committee made this recommendation, see the rationale section on choice of antimicrobial for impetigo.

Full details of the evidence and the committee's discussion are in evidence review.

Terms used in the guideline

Non-bullous impetigo

Impetigo characterised by thin-walled vesicles or pustules that rupture quickly, forming a golden-brown crust.

Bullous impetigo

Impetigo characterised by the presence of fluid-filled vesicles and blisters often with a diameter of over 1 cm that rupture, leaving a thin, flat, yellow-brown crust.

Decolonisation

Use of topical treatments (antiseptic body wash, nasal ointment or a combination of both) and personal hygiene measures to remove the bacteria causing the infection from the body.