Introduction

Looking after your skin is one of the most important aspects of personal hygiene and self-care. Whether it’s on your own skin or your child’s, a rash can be a cause for concern. In most cases, rashes that have a crusty exterior are likely to be impetigo - a bacterial infection on the surface of the skin. This condition is very common; in fact, it is the most common skin infection present in young children.¹ These rashes can appear anywhere but are more likely on the face, especially around the mouth and nose, and on the hands. Thankfully, impetigo can be treated at home and usually clears up within a week. But what if your impetigo keeps coming back? In this case, your condition is known as recurrent impetigo and can be a sign of a more serious infection. This article will discuss the symptoms and causes of impetigo, along with how to manage the condition and when to seek medical help.

What is recurrent impetigo?

Impetigo is a common, highly contagious skin condition that is most common among children aged 2-5 years but can affect people of all ages.² In general, impetigo is characterised by the appearance of small, pus-filled blisters surrounded by reddened skin, which may burst to leave a yellow/brown crust.¹ These infected patches start off small but can expand across the skin. There are two types of impetigo; identifying which type you have will assist in the treatment process.

Non-bullous impetigo

The most common form of impetigo, non-bullous impetigo comprises 70% of cases and is also known as contagious impetigo. In this form, blisters form and burst shortly thereafter, leaving behind a thick honey-coloured crust.³ The bacteria Staphylococcus aureus is the primary cause of this type of impetigo, though Streptococcus pyogenes can cause the same reaction. These sores are usually painless, though the red areas around the crusts can be itchy. If untreated, non-bullous impetigo usually clears up within 2-3 weeks and does not scar.⁴ 

Bullous impetigo

Caused by S. aureus exclusively, bullous impetigo is named after the fluid-filled blisters (bullae) that are characteristic of this type. In this case, infection usually occurs in the torso area or on the arms and legs and can spread quickly.³ In contrast with non-bullous impetigo, the blisters can be painful and usually remain on the skin for a longer period, oozing yellow fluid before they finally burst, leaving a yellow crust. Once again, if untreated, this condition should resolve itself within 2-3 weeks.⁴ 

Symptoms of impetigo

Impetigo is most often identified by the physical manifestations of the infection. The physical appearance of each type is as follows:

• Non-bullous:
  • Present around the nose and mouth
  • Sores burst quickly
  • Leave a golden crust¹
• Bullous:
  • Present around the torso, on arms and legs
  • Fluid-filled blisters that burst after several days
  • Leave a honey-yellow crust¹ 

Further symptoms include:

• Red, sore, and itchy skin
• Fever
• Swollen glands
• General unwell feeling¹

Causes of impetigo

Knowing the causes of impetigo can help with prevention, especially when it comes to recurrent cases. Bacteria enter the layers of the skin in one of two ways:

1. Primary: bacteria enter healthy skin through a break, such as a cut, insect bite, burn, etc
2. Secondary: bacteria enter areas damaged by other skin conditions, such as eczema, scabies, or head lice³ 

It is important to be careful when you or someone you’re caring for has impetigo, as the condition is extremely contagious. Physical contact or the sharing of towels, washcloths, and bedding can spread the bacteria easily. In most cases, you won’t even realise you’ve spread or caught impetigo, as symptoms can take between 4 and 10 days to show after your initial exposure. 

You are more at risk of impetigo if you are diabetic or have a weakened immune system, and children are a high-risk group as bacteria can travel quickly within nursery and daycare settings. Your environment can also play a part in your susceptibility to impetigo, as infections are more common in humid climates and crowded living arrangements.⁵ 

If your impetigo is recurrent, you should visit a healthcare professional who can perform a culture and susceptibility (C&S) swab. This aims to identify the cause of recurrence, such as methicillin-resistant S. aureus (MRSA), which can live in the nasal cavities and cause impetigo to return after the initial infection has cleared.⁶ 

Managing impetigo

If left untreated, impetigo usually clears up in 2-3 weeks. However, with simple, at-home treatment, the rashes can clear in just a few days. The British Association of Dermatologists recommends the following treatment regime:

1. Gently remove crusts as they form using antibacterial soap/skin wash, and water
2. Apply 1% hydrogen peroxide antiseptic cream to the affected areas 2-3 times a day for 5-7 days
3. If this is ineffective, your doctor can prescribe antibiotic creams such as mupirocin or fusidic acid. Apply these 3-4 times a day for 5-7 days

In cases of recurrent or widespread impetigo, oral antibiotics may be prescribed, such as flucloxacillin or clarithromycin.¹

It must be noted that antibiotic resistance is an ongoing issue in the treatment of bacterial infections, so it is important that antibiotics are only used when absolutely necessary. 

With recurrent impetigo, it is important to take proper care of your skin to prevent another outbreak. Ensure any breaks in the skin, like cuts and bites, are kept clean, washed with antiseptic, and dressed correctly. If you have a pre-existing skin condition like eczema, keep these areas clean and seek the relevant treatment to minimise the chance of bacterial infection.³ As previously mentioned, a nasal C&S swab can identify the cause of recurrent impetigo. Once identified, your doctor may prescribe an antiseptic nasal cream to be applied at least once a day for 5-10 days. This will attempt to clear out the bacteria and prevent the recurrence of impetigo.⁶ 

If nasal treatment does not fully solve the issue, you may be recommended to undertake decolonisation. This involves a combination of nasal ointment, oral antibiotics, full-body antiseptic washes, and general improvements in personal hygiene.⁵ 

Summary

Recurrent impetigo is a common skin infection caused by bacteria entering a break in the skin. The main symptoms are patches of sore skin covered in blisters, which may remain filled for a time or burst soon after forming. In either case, once the blisters have burst, the area becomes crusted over and will slowly begin to heal. These blisters may be painful, but in most cases, they just produce an itchy feeling. It is important to resist this feeling, however, as this will allow the virus to spread. Other risk factors for impetigo include poor hygiene, living in a humid environment, and being immunocompromised. If you or your child are currently suffering from impetigo, the best way to clear up the infection and protect others is through proper care of infected areas. Regularly clearing away the crusts and washing with antiseptic wash should speed up the healing process, which would take weeks otherwise. In the case of recurrent impetigo, bacteria may be living within your nasal cavities, lying dormant until a break in the skin allows for re-infection. A nasal swab can identify this as the cause, and subsequent use of nasal ointment should clear out the infection for good. Impetigo is an annoying but usually manageable infection whose recurrence can be prevented with the right care.