Impetigo: Treating and Preventing This Common Skin Infection

Two types of bacteria primarily cause impetigo: Staphylococcus aureus and Streptococcus pyogenes (a group A streptococcus).  These bacteria are commonly found on the skin and nose but usually do not cause harm unless there is a break in the skin. When the skin is damaged due to an insect bite, eczema, or other forms of irritation, these bacteria can enter and lead to an infection.

The infection often begins at the site of damaged skin. For example, a small cut or scratch can provide an entry point for the bacteria. Conditions like eczema or dermatitis can also make the skin more susceptible to impetigo by creating a compromised barrier.

Symptoms of Impetigo

The infection often starts with red spots that quickly develop into small, fluid-filled blisters. These blisters may burst, leaving behind open sores covered by a characteristic honey-coloured crust. Often described as cornflake-like.

If left untreated, impetigo can spread to other parts of the body. The affected area might become increasingly painful, and the sores may spread or merge, leading to larger areas of infection.

While impetigo primarily affects the skin, severe cases might result in fever or other systemic symptoms. This is less common but can occur if the infection spreads beyond the skin.

Is impetigo contagious?

This infection is contagious. As the full name, impetigo contagiosa suggests, this infection spreads very easily - to other parts of the body and to your nearest and dearest. Keep a strict household - don't share towels or bedding, wash hands regularly, and keep open sores covered with bandages. You stop being infective after 48 hours of treatment or after all infected areas have dried up. You should consider staying away from work during this time, avoid preparing food for others and avoid shared areas such as gyms or contact sports.

Medical History

To accurately diagnose impetigo, healthcare providers start with a detailed discussion of the patient’s medical history. This includes asking about recent skin injuries, pre-existing skin conditions (like eczema, cold sores or psoriasis), and exposure to others with similar symptoms. It’s essential to provide information about recent insect bites, cuts, or abrasions, as these can serve as entry points for the infection.

Physical Examination

The healthcare provider will inspect the affected area closely during a physical examination. Impetigo is typically characterised by its distinct appearance:

• Red sores: Initially, the infection appears as red spots or bumps on the skin.

• Blisters: These spots can develop into small blisters filled with fluid.

• Crusting: The blisters eventually burst and form a characteristic honey-coloured or brown crust. This progression helps differentiate impetigo from other skin conditions.

In some cases, additional tests may be necessary to confirm the diagnosis or rule out other conditions:

• Swab testing - A swab of the infected area is often taken to identify the bacteria responsible for the infection. This can help determine if Staphylococcus aureus, Streptococcus pyogenes, or another bacterium cause the disease.

• Blood tests - If the infection is severe or has systemic symptoms, blood tests may be conducted to assess overall health and check for signs of a more serious underlying condition.

• Patch testing - If there's uncertainty about whether the condition is impetigo or another type of dermatitis, patch testing might be used to identify allergic reactions that could contribute to skin issues.

Cold Sores vs. Impetigo

It’s essential to distinguish impetigo from other conditions, such as cold sores:

• Cold sores - Caused by the herpes simplex virus, cold sores appear as small blisters, often around the mouth or nose. They usually have a different appearance than impetigo and are not covered by a crust. However, if the sores become open wounds, they can lead to impetigo if they become infected.

• Impetigo - Impetigo typically presents with red sores and crusts, which may follow minor skin damage or a pre-existing skin condition.

Over-the-counter treatments

While impetigo generally requires prescription medication, some over-the-counter products can help manage symptoms and prevent the spread of the infection:

• Using gentle antibacterial soaps to clean the affected area can help remove bacteria and reduce the risk of spreading the infection.

• Crystacide 1% cream containing 1% Hydrogen peroxide as the active ingredient is effective at treating small localised lesions of impetigo and is available behind the pharmacy only.

• Other healthcare products containing antiseptics like TCP or Hibiscrub may provide temporary relief and can help maintain cleanliness but should not replace prescribed antibiotics.

Prescription Medications

Treatment for impetigo typically involves antibiotics, which can be administered topically or orally depending on the severity of the infection:

• Topical antibiotics - Creams or ointments containing antibiotics such as mupirocin or fusidic acid (Fucibet) are applied directly to the infected area. These are effective for mild cases and can help clear the infection from the skin.

• Oral antibiotics - Oral antibiotics like flucloxacillin, clarithromycin, or erythromycin may be prescribed for more extensive infections or when topical treatments are insufficient. These are necessary when the infection covers a larger area or has spread beyond the initial site.

Self Care

In addition to medication, proper home care is crucial for managing impetigo:

• Cleaning the affected Area - Wash the infected area with mild soap and water to keep it clean and remove any crusts gently. This helps prevent the spread of bacteria and supports the healing process.

• Avoiding scratching - To prevent further infection and spreading, it is essential to avoid scratching or picking at the sores. This also helps reduce the risk of scarring.

• Covering sores - Keeping them covered with clean, breathable bandages can protect them from further irritation and reduce the risk of transmission to others.

• Hygiene practices: Regular hand washing is essential, especially after touching the infected area. Avoid sharing towels, bedding, or personal items with others.

• Environmental control: Clean and disinfect common areas and surfaces to reduce the risk of spreading the bacteria. This is particularly important in shared living spaces or communal areas like schools or daycare centres.

Impetigo in Children

Impetigo is particularly common in children due to their active nature and frequent contact with others. It is essential to follow these additional considerations for children:

• Children with impetigo should be kept home from school or daycare until they have received treatment for at least 48 hours and the sores have started to heal.

• Educate parents and caregivers about the importance of adhering to treatment and maintaining hygiene to prevent the infection from spreading.

• Children with chronic conditions or weakened immune systems may experience more severe infections and require more intensive treatment.

Healthwords pharmacists' top tips

There are limited treatments available from the pharmacy that will treat Impetigo effectively. Impetigo often requires treatment with prescription-only medicines prescribed by your doctor, or via an accredited pharmacist through an NHS Pharmacy First consultation scheme specific for Impetigo. These may include antibiotic creams to be applied topically or systemically with antibiotic tablets, capsules, or suspensions.

Prevention of Impetigo

Maintaining excellent hygiene is crucial to prevent impetigo from developing or spreading:

• Regular hand washing with soap and water is one of the most effective ways to prevent the transmission of bacteria. Ensure hands are washed thoroughly, especially before eating or touching the face.

• Promptly clean any cuts, scrapes, or insect bites with soap and water. Applying an antiseptic can help prevent bacteria from entering the skin.

• Avoid close contact with individuals with active impetigo until they have been treated and are no longer contagious.

• Do not share towels, bedding, or personal items with someone with impetigo. Wash these items in hot water and dry them thoroughly.

• Clean and disinfect commonly touched surfaces, such as door handles and countertops, to eliminate bacteria.

• Wash clothing, bed linens, and towels regularly to reduce the risk of bacterial transmission.

• Manage conditions like eczema, psoriasis, or other skin issues that can make the skin more prone to infection.

Am I fit for work?

You should consider being off work for 48 hours after treatment has started or - if you do not get treatment - once the infection has dried out. It is unlikely you feel unwell or even uncomfortable with this condition, but absence from work is to avoid passing this contagious infection on to co-workers.

Book an urgent appointment with your doctor, who will assess this and may give antibiotic cream or tablets. Occasionally impetigo can go beyond the top-most layers of skin, causing cellulitis or ecthyma, where ulcers develop, so it is worth getting checked if treatment is not helping or your condition is worsening.

Complications of Impetigo

Cellulitis

Impetigo can sometimes progress to cellulitis, a deeper bacterial infection of the skin and subcutaneous tissues:

• Cellulitis is characterised by increased redness, swelling, warmth, and pain in the affected area. Fever and chills may also be present.

• Immediate medical attention is required to treat cellulitis with appropriate antibiotics.

Ecthyma

Ecthyma is a more severe form of impetigo where ulcers form beneath the crust:

• This condition is marked by deeper, painful ulcers that may scar if not treated properly.

• Ecthyma requires prompt treatment with systemic antibiotics and sometimes additional care for wound healing.

Scarring

If impetigo is not treated properly, it can result in scarring:

• Follow prescribed treatments and avoid picking at sores to minimise the risk of scarring.

Systemic Infections

In rare cases, bacteria from impetigo can enter the bloodstream and cause more severe infections:

• Symptoms may include high fever, chills, and rapid worsening of the condition.

• Systemic infections require immediate medical intervention with intravenous antibiotics and hospital care.