Impetigo is a contagious yet generally non-severe skin condition that results from bacterial infection. This condition leads to sores and blisters, which could burst and form honey-coloured, crusty patches on the skin that can be itchy and painful.^1,2 

Although impetigo can appear at any age, children are most likely to experience it, particularly between the ages of two and five.³ Since it can spread through direct contact, preventing impetigo is crucial.²

If left untreated, it can spread quickly to other people, particularly in settings like schools, offices, nurseries, or homes where close contact is common¹. Effectively preventing impetigo protects you from discomfort, itching, and the risk of scarring and promotes overall skin health and quality of life.

Therefore, this article aims to provide a comprehensive guide on tips for preventing and controlling the spread of impetigo.

Understanding impetigo

Two types of bacteria primarily cause impetigo: Staphylococcus aureus and Streptococcus pyogenes.² There are two types of impetigo: bullous and non-bullous (school sores).

• Non-bullous impetigo: Either Streptococcus pyogenes or Staphylococcus aureus can cause non-bullous impetigo. Healthy skin is normally resistant to these bacteria.  However, it can get infected when the skin becomes interrupted, by wounds, scrapes, insect bites etc.^{2, 4}
• Bullous impetigo: This type of impetigo is caused by Staphylococcus aureus, which produces exfoliative toxins. These toxins can exfoliate your skin by attacking intracellular adhesion molecules (desmoglein-1, found in the granular layer of the epidermis) which induces blister development by causing the epidermal cells to separate. This type of impetigo can develop even on healthy and intact skin.²

Symptoms 

It is crucial to recognise the symptoms of impetigo for proper treatment.

• Initial symptoms include red sores or blisters. However, dark and black skin may hide the redness more easily.
• Lesions typically appear on the face, especially around the nose and mouth, but can spread to other body parts.
• Crusty, golden-brown patches are left behind after the sores or blisters explode swiftly.

These patches can:

• appear like cornflakes glued to your skin
• expand/ get larger
• cause itching and occasionally serious pain¹

Risk factors 

Impetigo is more prevalent in:

• Hot and humid conditions
• Unsanitary conditions, including crowded living quarters, or through intimate physical touch, eg. contact sports
• Individuals with skin disorders or injuries that compromise the integrity of the skin barrier, such as scabies, eczema, fungal skin infections, abrasions, and insect bites
• Diabetes mellitus patients
• Those with weakened immune systems
• Individuals who use intravenous drugs⁵

Strategies to prevent and control impetigo 

Personal hygiene

Maintaining proper hygiene is crucial for avoiding the spread of this condition. It involves hygiene practices like bathing daily, especially hand hygiene like regular washing of hands, particularly before and after applying creams and after using the toilet. 

Also trimming your fingernails short and clean is crucial as germs can grow under your nails, and also to prevent scratching, which can worsen the condition.⁶

Proper wound care and skin hygiene

Proper wound care and skin hygiene practices involve:

• Covering the infected areas with a waterproof dressing to stop spread: It is usually advised to cover exposed infected regions with gauze and tapes or apply a loose plastic bandage to prevent impetigo from spreading to other body parts. 
• Frequently mild cleaning of the regions to remove the formed crusts: to aid the removal of the crusty layers, soak any affected skin regions in warm, soapy water. 
• Cleaning using antiseptic soaps. 
• Refraining from touching infected areas.
• Every time you wash, use a fresh towel or washcloth. 

By doing this, you might stop the impetigo from spreading across different body areas. Use an anti-itch medication if the skin is itching excessively and to prevent scratching.^{6, 7}

 Environmental controls

• Wash and pat dry the infected areas with a fresh towel each time.
• Every day, change clothes and bedding and use hot water while washing.
• If someone in your family has impetigo, advise them to cover sores with gauze and tape.
• Avoid sharing personal items. Ensure that everyone in the family uses their clothes, towels, facecloths, soaps, razors, loofah sponges, and bedding to stop the transmission of impetigo. If someone has impetigo, separate their clothes, towels, and bed linens and wash them with hot water.
• Washing together should only involve items that belong to the affected individual. Wash any clothing or linens belonging to a different family member in a different load.
• Maintain your home's and kitchen's surfaces tidy. Doorknobs, countertops, light switches, and other surfaces touched by the impetigo individual should be disinfected. By doing this, others may avoid contracting impetigo.^{6, 7}

Behavioural measures

• Steer clear of direct skin-to-skin contact until your sores and blisters crust over or you have been taking antibiotics for 24 to 48 hours.
• Avoid contact with others. Children in school, nursery, sports teams, etc. should remain at home till their lesions become crusted over or they have had treatment for at least 24 hours.
• Being tempted to touch or itch your sores should be avoided to prevent the risk of infecting other body parts.
• Encourage infected children not to share personal items (towels, toys).^{6, 7}

Treatment

Topical Antibiotics 

• When antiseptic treatment has not resolved or is not suitable, topical antibiotics may be tried (e.g. impetigo surrounding your eyes).
• Antibiotic ointments 2-3 times a day for 5-7 days are advised for localised non-bullous impetigo (e.g., hydrogen peroxide 1% cream or povidone-iodine 10% ointment). 
• Topical antibiotics, like mupirocin or fusidic acid, work well for managing non-bullous impetigo, nevertheless, because of bacterial resistance, their usage may not be advised in some nations.⁶ 

Oral antibiotics

• The healthcare provider might suggest taking an antibiotic tablet or liquid for 7–10 days if the infection has spread to other body parts or the ointment doesn't seem to be helping.
• It is suggested in cases of bullous impetigo, extensive non-bullous impetigo (>3 lesions), if topical therapy is ineffective when a patient is at a greater risk of adverse effects, or in cases of systemic illness. 
• The initial antibiotic of choice is frequently flucloxacillin taken orally.  
• Erythromycin or trimethoprim + sulfamethoxazole are possible substitutes.⁶ 

Note for parents: Healing ought to begin after a few days of starting antibiotic medication. Parents should ensure that their child takes their medication as directed. If not, a more severe and profound skin infection can arise. 

They should also monitor children for signs of infection and educate them about good hygiene practices. Contact the physician if the lesions don't heal after three days if a fever appears, and if the region surrounding the rash turns red, warm, or painful to the touch.⁸

Prevention

Sadly, the infection may recur even after impetigo has healed. 

1. Maintaining clean skin might aid in preventing impetigo. Particular attention should be given to eczema patches, poison ivy rashes, and other skin problems. Maintain these areas covered and clean.
2. Wounds on the skin should be treated immediately. Wash any cuts, scrapes, bug bites, or other wounds you (or your kid) sustain immediately with soap and water. Next, put on a bandage and an antibiotic ointment.
3. When your child has a runny nose, clean the area between the upper lip and nose and apply anti-bacterial ointment under and inside the nostrils, using a Q-tip as the nose is a frequent source of impetigo germs.
4. When someone has impetigo, refrain from touching their skin or whatever the other person has touched, such as bedding, towels, clothing, toys, and athletic equipment.
5. After each sporting practice, take a shower. When drying off, use a disposable or clean towel each time.
6. After using the loo, wash your hands using soap and a clean towel to dry.
7. Wear clean clothes. Refrain from removing dirty clothes from the washing basket, particularly those used for exercise.
8. Use proper handwashing techniques by rubbing your hands for at least 20 seconds. If soap is not available, use alcohol-based hand sanitiser with at least 60% alchohol.^{5,7, 8}

FAQs

What are the potential consequences if impetigo is left untreated?

When impetigo is not treated, painful blisters and deeper ulcerations can develop, referred to as ecthyma. It may result in kidney inflammation and permanent skin scars. Cellulitis is an illness that affects the tissue beneath the skin, and it can also result from impetigo. 

Additionally, this infection can become fatal by spreading to the blood circulation and lymph nodes.⁷

What are the complications of impetigo?

Complications of impetigo can include rare but serious conditions such as 

• Post-streptococcal glomerulonephritis, 
• Scarring, 
• Widespread infections such as cellulitis, 
• Lymphangitis, 
• Bacteremia, 
• Staphylococcal scalded skin syndrome, 
• Streptococcal toxic shock syndrome, 
• Post-inflammatory pigmentation, 
• Scarlet fever
• Rheumatic fever.^6,5

Summary

Impetigo is a highly infectious bacterial skin disease that mostly affects children. It usually appears as blisters or red sores that eventually become honey-coloured crusts. Treatment choices may range from topical antibiotics to oral drugs based on the severity of the infection.

To avoid its onset, practising good personal and hand hygiene is crucial. Proper wound care and covering, avoiding direct skin-to-skin contact, and avoiding sharing personal items can help to prevent the spread. Early symptom detection, attentive wound care, and following preventative measures are essential for controlling and avoiding impetigo outbreaks.