IMPETIGO

• Non-bullous impetigo: This is the more common form, caused by both staph and strep bacteria. This form initially presents as small red papules similar to insect bites. These lesions rapidly evolve to small blisters and then to pustules that finally scab over with a characteristic honey-colored crust. This entire process usually takes several days. These lesions often start around the nose and on the face, but less frequently they may also affect the arms and legs. At times, there may be swollen but non-tender lymph nodes (glands) nearby.
• Bullous impetigo: This form of impetigo is caused only by staph bacteria. These bacteria produce a toxin that reduces cell-to-cell stickiness (adhesion) causing separation between the top skin layer (epidermis) and the lower layer (dermis). This leads to the formation of a blister. (The medical term for blister is bulla.) Bullae can appear in various skin areas, especially the buttocks and trunk. These blisters are fragile and contain a clear yellow-colored fluid. The bullae are delicate and often break and leave red, raw skin with a ragged edge. A dark crust will commonly develop during the final stages of development. With healing, this crust will resolve.TREATMENT
• mpetigo is not serious and is very treatable. Mild impetigo can be handled by gentle cleansing, removing crusts, and applying the prescription-strength antibiotic ointment mupirocin (Bactroban). Nonprescription topical antibiotic ointments (such as Neosporin) generally are not effective. More severe or widespread impetigo, especially of bullous impetigo, may require oral antibiotic medication. In recent years, more staph germs have developed resistance to standard antibiotics. Bacterial culture tests can help guide the use of proper oral therapy if needed. Antibiotics which can be helpful include penicillin derivatives (such as Augmentin) and cephalosporins such as cephalexin (Keflex). If clinical suspicion supported by culture results show other bacteria, such as drug-resistant staph (methicillin-resistant Staphylococcus aureus or MRSA), other antibiotics such as clindamycin or trimethoprim-sulfamethoxazole (Bactrim or Septra) may be necessary. Treatment is guided by laboratory results (culture and sensitivity tests).
• Treatment of impetigo typically involves local wound care along with antibiotic therapy. Antibiotic therapy for impetigo may be with a topical agent alone or a combination of systemic and topical agents. Gentle cleansing, removal of the honey-colored crusts of nonbullous impetigo using antibacterial soap and a washcloth, and frequent application of wet dressings to areas affected by lesions are recommended. Good hygiene with antibacterial washes, such as chlorhexidine or sodium hypochlorite baths, may prevent the transmission of impetigo and prevent recurrences, but the efficacy of this has not been proven.
  For antibiotic therapy, the chosen agent must provide coverage against both Staphylococcus aureus and Streptococcus pyogenes. The prevalence of methicillin-resistant S aureus (MRSA) and macrolide-resistant Streptococcus has changed empiric treatment options for impetigo. MRSA was responsible for 78% of all community staphylococcal-related skin and soft tissue skin infections in a multicenter US study.^[34]
  As community-acquired MRSA (CA-MRSA) infection most commonly manifests as folliculitis or abscess, rather than impetigo, beta-lactam drugs remain an appropriate initial empiric choice. However, the continued increased presence of CA-MRSA may limit the utility of these agents. In this situation, clindamycin or doxycycline in children older than 8 years can be used if the isolate is susceptible.^[35] Trimethoprim-sulfamethoxazole can be used in situations in which group A streptococci are unlikely.
  Topical mupirocin or retapamulin is adequate treatment for single lesions of nonbullous impetigo or small areas of involvement. Systemic antibiotics are indicated for nonbullous impetigo with extensive involvement, in athletic teams, childcare clusters, multiple family members, or for s bullous impetigo.^[26]
  In pati
  ents with bullous impetigo who present to the emergency department with large areas of involvement resulting in denuded skin from ruptured bullae, management also includes intravenous fluid resuscitation. Fluid is given at a volume and rate similar to standard volume replacement for burns.
  Inpatient care is required for patients with impetigo who have widespread disease or for infants at risk of sepsis and/or dehydration due to skin loss. If inpatient care is warranted in the child with untreated impetigo, contact isolation is recommended.
  A clinical guideline summary from the Infectious Diseases Society of America that includes recommendations on impetigo, Practice guidelines for the diagnosis and management of skin and soft-tissue infections, may be helpful.