localized impetigo as fewer than ten lesions and an affected area smaller than 36 cm2. The panel adopted this description of localized impetigo. Apart from the clinical presentation, underlying conditions such as a compromised immune status should be considered when defining treatment.10,19,46,47
Differential Diagnosis
For nonbullous impetigo, the differential diagnosis includes contact dermatitis, eczema herpeticum, herpes simplex, scabies, pemphigus foliaceous, and tinea infection. The presence of the characteristic golden crust should raise suspicion for impetigo.5 The bullous form should be distinguished from other blistering skin conditions such as acute contact dermatitis, bullous drug eruptions, burns, bullous insect bite reactions, varicella, and subcorneal pustular dermatosis, Stevens-Johnson syndrome, and other bullous diseases (ie, bullous pemphigoid).10,20
Impetigo is a clinical diagnosis, although Gram stain and culture of the skin lesions are useful for identifying causative pathogens. Culture and sensitivity testing allow clinicians to detect antimicrobial susceptibilities and support prescription of the most appropriate antibiotic treatment. This approach is especially important when MRSA infection is being considered, though empiric coverage for MRSA may be instituted if clinical suspicion is high.10
Although complications of non-bullous impetigo are rare, local and systemic spread of infection can occur that may result in cellulitis, lymphangitis, or septicemia.5,10 Complications of S. pyogenes infection include scarlet fever, guttate psoriasis, and post-streptococcal glomerulonephritis.5
Treatment of Impetigo
Typically, impetigo, whether non-bullous or bullous, is self-limiting and is resolved without scarring within two to three weeks.5,10 Reasons for the treatment of impetigo include preventing the spread of infection, hastening the resolution of discomfort, and improving cosmetic appearance.10 Bullous and non-bullous impetigo can be treated with either topical or oral therapy. Topical therapy is used for patients with limited skin involvement, whereas oral treatment is recommended for patients with extensive impetigo involvement.5,10
In healthcare settings, contact precautions to avoid the spread of impetigo are indicated until 24 hours after the start of appropriate antibiotic therapy.
The algorithm for treatment decision is depicted in Figure 2A, and the steps in the treatment of impetigo are shown in Figure 2B.10 When a patient presents with impetigo, a Gram stain and culture of pus or exudate may be performed.10 In localized cases defined as fewer than ten lesions and smaller than 36 cm2 area affected, in those that are systemically stable and with a low risk of complications, topical ozenoxacin cream 1%, topical mupirocin 2% ointment,5 fusidic acid 2% cream or retapamulin 1% ointment are recommended (Table 1).5,10 Cleanse the skin and remove the crusts before the application of the topical treatment.10
During the panel discussions, the use of a topical antibiotic rotation regime, for instance, was mentioned in the case of recurrent infection. In the USA, the topical regime may comprise a rotation of mupirocin and ozenoxacin cream 1%, and in Europe, a rotation of mupirocin, ozenoxacin, and fusidic acid may be used.
According to the panel, systemic antibiotic treatment for impetigo patients may differ between the USA and Europe. In the
Differential Diagnosis
For nonbullous impetigo, the differential diagnosis includes contact dermatitis, eczema herpeticum, herpes simplex, scabies, pemphigus foliaceous, and tinea infection. The presence of the characteristic golden crust should raise suspicion for impetigo.5 The bullous form should be distinguished from other blistering skin conditions such as acute contact dermatitis, bullous drug eruptions, burns, bullous insect bite reactions, varicella, and subcorneal pustular dermatosis, Stevens-Johnson syndrome, and other bullous diseases (ie, bullous pemphigoid).10,20
Impetigo is a clinical diagnosis, although Gram stain and culture of the skin lesions are useful for identifying causative pathogens. Culture and sensitivity testing allow clinicians to detect antimicrobial susceptibilities and support prescription of the most appropriate antibiotic treatment. This approach is especially important when MRSA infection is being considered, though empiric coverage for MRSA may be instituted if clinical suspicion is high.10
Although complications of non-bullous impetigo are rare, local and systemic spread of infection can occur that may result in cellulitis, lymphangitis, or septicemia.5,10 Complications of S. pyogenes infection include scarlet fever, guttate psoriasis, and post-streptococcal glomerulonephritis.5
Treatment of Impetigo
Typically, impetigo, whether non-bullous or bullous, is self-limiting and is resolved without scarring within two to three weeks.5,10 Reasons for the treatment of impetigo include preventing the spread of infection, hastening the resolution of discomfort, and improving cosmetic appearance.10 Bullous and non-bullous impetigo can be treated with either topical or oral therapy. Topical therapy is used for patients with limited skin involvement, whereas oral treatment is recommended for patients with extensive impetigo involvement.5,10
In healthcare settings, contact precautions to avoid the spread of impetigo are indicated until 24 hours after the start of appropriate antibiotic therapy.
The algorithm for treatment decision is depicted in Figure 2A, and the steps in the treatment of impetigo are shown in Figure 2B.10 When a patient presents with impetigo, a Gram stain and culture of pus or exudate may be performed.10 In localized cases defined as fewer than ten lesions and smaller than 36 cm2 area affected, in those that are systemically stable and with a low risk of complications, topical ozenoxacin cream 1%, topical mupirocin 2% ointment,5 fusidic acid 2% cream or retapamulin 1% ointment are recommended (Table 1).5,10 Cleanse the skin and remove the crusts before the application of the topical treatment.10
During the panel discussions, the use of a topical antibiotic rotation regime, for instance, was mentioned in the case of recurrent infection. In the USA, the topical regime may comprise a rotation of mupirocin and ozenoxacin cream 1%, and in Europe, a rotation of mupirocin, ozenoxacin, and fusidic acid may be used.
According to the panel, systemic antibiotic treatment for impetigo patients may differ between the USA and Europe. In the
