Understanding impetigo

Impetigo (im-puh-ty-go) is a skin infection caused by gram-positive bacteria which affects the superficial layers of the epidermis (outermost layer of skin). It is highly contagious and can be extremely uncomfortable for sufferers due to intense itching and often pain. Improving the condition of impetigo-affected skin is crucial in trying to reduce this irritation. The infection is most common in children which typically affects the face and often thrives in hot climates.¹ The typical appearance of this condition is a honey-coloured, scab-like lesion.² 

There are two types of impetigo; bullous and non-bullous, with the main difference being the severity of symptoms. With non-bullous impetigo the symptoms are typically milder and infrequent, slight itching is most commonly reported, whereas bullous impetigo can provoke symptoms ranging from visible blisters and sores to more widespread fevers and muscle weakness. 

When it comes to treating Impetigo antibiotics are the first point of call, whether that be topical or oral, yet many preventative practices can be put in place to avoid the contraction of the bacteria. 

Pathology of impetigo

Gram-positive bacteria are the main culprits in impetigo, with the majority of cases being caused by Staphylococcus aureus and a small number of cases caused by Streptococcus pyogenes. The trigger for this infection is anything ranging from physical lacerations, insect bites, or general trauma. 

There is subsequently a breach of the skin’s defences and the bacteria is able to enter through breaks in the skin.³ Once inside the body, the bacteria can multiply forming a colony that produces toxins. This release of harmful substances then weakens the skin cells. In cases of bullous impetigo, toxins that have been produced by staphylococcus aureus can lead to the formation of blisters by breaking the connections between skin cells, liquid then gathers in these gaps and the blister is created. 

In response to this damage, the immune system releases white blood cells causing inflammation that is seen as pus in the lesions caused by impetigo.⁴

Treatment strategies

Medication

Topical antibiotics 

These are first-line treatment ointments that can be prescribed for Impetigo, three of the most regularly used in mild cases of this condition are:

• Mupirocin (Bactroban) - An ointment that is directly applied to the affected area twice a day for five to ten days. It is important that this product is used for no longer than the directed length of time and is kept away from the mouth, nose and eyes.⁵
• Fusidic acid - A cream/ointment usually applied three or four times a day for a period of one to two weeks. To avoid reinfection it is vital that the full prescribed course of treatment is carried out.⁶
• Ozenoxacin cream - Used to treat impetigo due to inhibition of methicillin-susceptible resistant strains (MRSA). Ideal for localised infection.⁷

Oral antibiotics  

Oral antibiotics are often reserved for severe cases of Impetigo, including widespread outbreaks, bullous impetigo, impetigo unaffected by ointments, and cases with underlying health conditions.⁸

Some of the most common antibiotics used are:

• Flucloxacillin - This is usually the first choice of antibiotic due to its particular success against Staphylococcus aureus, a common contributor of impetigo.⁹
• Cephalexin - used for widespread impetigo this antibiotic should be taken for seven days in four doses.¹⁰
• Amoxicillin-clavulanate - This is a combination penicillin antibiotic that can be used when the impetigo-causing bacteria is unknown or resistant.¹¹ 

Home care practices  

For less severe cases of impetigo, over-the-counter medications can be administered with the infected areas then covered and left.¹² To try and speed up the recovery of impetigo, care of the affected skin is essential. This can involve:

• Gentle Cleansing - The sores should be treated with soapy water each day. This can help to keep the area clean and soften the crusts that form so that they can be removed. This can allow for the antibiotic ointments to be absorbed more effectively at the site of infection.¹³
• General Hygiene - Implementing regular handwashing and the use of alcohol-based sanitiser can reduce the chance of spreading infection.
• Keep the area covered - Using gauze and loose bandages can give the skin an opportunity to heal.

Some natural remedies can help ease the symptoms and make the period of treatment more bearable, it is advised that these natural treatments are used in combination with prescribed medications.¹⁴

• Honey (specifically manuka) - Can contribute to inhibiting bacterial growth at the site of the wound.
• Tea tree oil - Diluted to a concentration suitable for direct topical application, this can reduce inflammation and inhibit bacterial growth.
• Aloe vera - Gel and cream products can soothe inflammation and encourage healing.

Preventing the spread

General hygiene is key in minimising the risk of spreading impetigo, especially due to the prevalence in younger children who are most often in germ-rich environments. There are some important practices to have in place to reduce infection of other parts of the body and other people.

• Try to avoid touching the affected areas of skin – this can be difficult due to the sites of impetigo often being found in the mouth, nose, and hands, yet this is important when stopping the transfer of bacteria
• Regular hand washing with antibacterial gel or soap
• Avoid sharing personal items such as towels, clothes, razors, and blankets. These materials can harbour the bacteria after contact with the infected skin
• Consistent disinfection of surfaces can be effective in containing impetigo– it is often surprising how many surfaces the human hands come in contact with daily, particularly focusing on areas including door knobs, countertops, phone screens, and taps

Additional tips

There are some additional methods that can care for impetigo-affected skin alongside prescribed medication.

• Soothing existing sores - Applying a cool compress in combination with a saline solution (salt dissolved in water) can help to reduce discomfort and any itching¹⁵
• Trying to resist scratching by wearing loose-fitting clothing
• Monitor progress – Keeping an eye on the improvement of the impetigo is vital, if the symptoms worsen rather than improve with treatment or a fever develops then a doctor must be contacted

Summary

Impetigo is a contagious bacterial infection affecting the skin. It is most common in children, causing uncomfortable, itchy, honey-coloured lesions with a scabby appearance. This usually occurs on the face. Two types of this condition exist; non-bullous with mild itching, and bullous, with blisters, fever, and weakness.

Staphylococcus aureus is the most prevalent bacteria in most cases of impetigo, entering and causing damage through cuts, bites, or eczema. This pathogen then multiplies and releases harmful toxins into skin cells resulting in the formation of blisters and pussy scabs.

Treatment often involves antibiotics, either topical ointments or oral medications for severe cases. Topical options include  Mupirocin (Bactroban), Fusidic acid, or Ozenoxacin cream for a more localised approach. Oral antibiotics like Flucloxacillin, Cephalexin, or Amoxicillin-clavulanate might be prescribed for wide outbreaks or ineffective topical treatment.

Home care can play a crucial role. Gentle cleansing of the sores daily can soften the crusts and promote antibiotic absorption. Maintaining good hygiene by frequent hand washing helps control the spread and covering the affected areas with loose bandaging can aid healing. Natural remedies can also offer some relief. Manuka honey helps inhibit bacterial growth, as well as tea tree oil which reduces inflammation. Aloe vera gel has been used to soothe irritation and encourage healing.

Preventing the spread of impetigo to other people or other parts of the body is really important. This can often be difficult among children. Avoiding contact with the sores and stopping the transfer of bacteria through shared items is effective in controlling the likelihood of a spread. If the condition becomes uncontrollable and symptoms start to worsen then medical attention should be sought.

FAQ’s 

How is impetigo diagnosed?

This most commonly requires a physical observation by a medical professional. If the diagnosis is questioned or treatment does not improve the condition then a bacterial culture can be carried out to identify the infection.

Can adults get impetigo?

 Yes; however, it is extremely uncommon due to adults having less skin-to-skin contact on a large scale like children do.

How long does it take for impetigo to go away?

The usual course for the prescribed antibiotics is 10 days but a noticeable response is often seen after the first three days.¹⁶ It is vital that regardless of this, the full course of antibiotics is completed.

When should I contact a doctor?

If you are unsure of the skin condition and what is causing it, then seeing a doctor can produce a fast diagnosis and treatment can start. Do not hesitate to contact your GP as soon as classic symptoms present themselves.¹⁷