Treatment Guideline Chart
Impetigo is a very contagious, superficial, bacterial skin infection that easily spreads among people in close contact.
Most cases occur in children and resolve spontaneously without scarring in approximately 14 days.
Ecthyma is a deeply ulcerated form of impetigo that extends to the dermis.
It has "punched-out" ulcers with yellow crust and elevated violaceous margins.
Most cases occur in children and elderly.
It may be a de novo infection or superinfection.

Impetigo%20-and-%20ecthyma Treatment

Principles of Therapy

  • Duration of treatment is tailored according to clinical improvement
    • If unresponsive or deteriorating, it is reasonable to extend beyond 7 days while waiting for the culture and sensitivity results

Topical Antibiotic Therapy

  • May be appropriate in localized nonbullous impetigo located away from the mouth (child may lick topical antibiotics if applied near the mouth)
  • Used to treat single lesions or small areas of involvement (localized impetigo)
  • Must be applied after crust removal to enhance penetration
    • Soften crusts with a wet cloth compress
    • Removal of scabs during the process of healing is not recommended
  • Use should be limited to 2 weeks due to risk of contact sensitization and antibiotic resistance development

Oral Antibiotic Therapy

  • Preferred treatment in patients with systemic symptoms, widespread nonbullous impetigo, lesions near the mouth, bullous impetigo, ecthyma patients in cases where there is evidence of deep involvement (eg cellulitis, furunculosis, etc), recurrent infection or in immunocompromised, those unable to tolerate topical antibiotics
  • Choice of agent will depend on suspected organism, local resistance patterns, cost and product availability
  • Parenteral antibiotics may be needed for widespread ecthyma


  • Topical antiseptics (eg Hydrogen peroxide cream) are not recommended due to limited evidence regarding its effectiveness and its tendency to cause skin reactions


Topical Antibiotics

Fusidic acid

  • 1st-line topical antibiotic
  • Effects: Has been proven to be as clinically effective as Mupirocin
    • Active against staphylococci (including Methicillin-resistant strains) and streptococci

Other Topical Antibiotics


  • Used for many years as topical therapy for localized impetigo
  • Effects: Has been shown to be effective against S aureus and group A streptococci


  • As Minocycline foam, showed moderate-to-excellent satisfaction and usability among the participants of a study conducted in Israel 


  • Effects: Has been proven to be as effective as Fusidic acid and several oral antibiotics (eg Ampicillin, Dicloxacillin, Erythromycin and Cefalexin) for treatment of impetigo and produces fewer side effects than oral agents
    • Considered as 2nd line of treatment after Fusidic acid as it is active against staphylococci (including Methicillin-resistant strains) and streptococci
  • Carriers of S aureus in their nares are treated with Mupirocin ointment applied nasally


  • Approved by the US FDA for the treatment of impetigo
  • Studies done in nonendemic settings showed superior efficacy when compared to placebo
    • Although with less clinical success rate compared to Retapamulin or Fusidic acid


  • Treatment option for impetigo with a short treatment duration of only 5 days
  • Considered as a 2nd-line treatment because of its cost
  • Suitable alternative to Fusidic acid
  • Effects: Active against S aureus and streptococci
    • In vitro data show activity against Methicillin-resistant staphylococci

Oral Antibiotics

Antistaphylococcal Penicillins

  • Dicloxacillin and Flucloxacillin
    • For infections caused by penicillinase-producing staphylococci
    • May be used to initiate therapy when staphylococcal infection is suspected
    • Very effective but less tolerated compared to Cefalexin
    • Does not cover Methicillin-resistant Staphylococcus aureus (MRSA)
  • Amoxicillin + Clavulanate
    • Indicated for impetigo and other skin and soft tissue infection caused by Methicillin-susceptible Staphylococcus aureus (MSSA)


  • First generation
    • Excellent activity against MSSA and S pyogenes
    • Generally well-tolerated
    • Do not cover MRSA
  • Second generation
    • Cefaclor, Cefprozil, and Cefuroxime are among the choices
  • Third generation
    • Variable in their activity against Gram-positive organisms especially MSSA and no inherent advantage to the broader Gram-negative coverage
      • Broad spectrum of activity tends to exert an increased selective pressure for emergence of antibiotic resistance


  • Alternative for Penicillin-allergic patients
  • Eg Azithromycin, Clarithromycin, or Roxithromycin
    • May be advantageous especially in instances of intolerance to Erythromycin but do not provide cure rates superior to Erythromycin
  • Erythromycin
    • Typically considered treatment of choice unless Erythromycin resistance is widespread in the community
    • Does not cover MRSA

Other Oral Antibiotics


  • Has very good activity against community-acquired MRSA but not to streptococci


  • Good choice for susceptible MRSA infections; however, there is a potential development of resistance with high-inoculum infections caused by Erythromycin-resistant strain


  • Good choice for mild to moderate bullous impetigo in patients from communities with high MRSA resistance


  • Eg Minocycline, Doxycycline
  • May be considered for mild to moderate MRSA infections
  • Contraindicated in children ≤8 years and during pregnancy

Other Agent

  • Topical gentian violet may be considered for patients with impetigo

Non-Pharmacological Therapy

  • Hygiene measures alone are not recommended even for localized lesions since untreated impetigo is highly communicable and may become generalized


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