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Impetigo is a superficial skin infection that occurs most commonly in children, particularly in those living in hot and clammy climates, in conditions of poor hygiene and overcrowding.

Impetigo - a superficial skin infection

Clinically, there are two recognized forms of impetigo, bullous and nonbullous (impetigo contagiosa). Bullous impetigo is invariably caused by Staphylococcus aureus, whereas the non-bullous type is caused by Staphylococcus aureus, group A Streptococcus (Streptococcus pyogenes), or both.

Impetigo lesions are highly contagious, with a peak incidence at 2 to 6 years of age, and can spread rapidly via direct contact. It is the third most common skin disease in children, after dermatitis and viral warts. The condition can develop either as a primary infection or secondary to pre-existing skin diseases such as atopic dermatitis, herpes simplex, or scabies where the integrity of the skin is disrupted. Scratching may further inoculate bacteria underneath the skin surface. The lesions generally develop as honey-colored (yellow brown) scabs, often found on the arms, legs, or the face. Rarely, patients may report burning and pruritus.

The diagnosis of impetigo is mostly based on the characteristic appearance of the lesions. However, certain diagnostic tests such as gram stain or bacterial culture may be required to make the diagnosis. Generally, patients who receive early and appropriate therapy recover well without scarring or complications within two weeks. Therapy for impetigo includes topical and systemic antibiotics. The topical antibiotics mupirocin and fusidic acid are very effective in mild cases of impetigo. Systemic antibiotics are useful for more extensive disease. Topical antiseptics help to soften crusts and clear exudate in mild disease and are useful adjuncts to antibiotics.

Impetigo Predisposing Factors

Bullous impetigo mostly affects infants and children younger than 2 years. Caused by toxin-producing S. aureus, it is a localized form of staphylococcal scalded skin syndrome. In contrast to non-bullous type of impetigo, bullous impetigo may sometimes involve the buccal mucous membranes.

Predisposing Factors

  • Minor skin trauma
  • Poor hygiene
  • Hot and humid weather
  • Over-crowded living conditions
  • Daycare attendance
  • Presence of co-morbid conditions
  • Malnutrition

Clinical features

The lesions of bullous impetigo are characterized by presence of flaccid, fluid filled vesicles and blisters (bullae) which are painful and related to systemic symptoms. The initial superficial vesicles rapidly develop to enlarging, flaccid bullae with sharp margins without surrounding erythema. The bullae initially contain a clear yellow fluid which later turns cloudy and dark yellow. The ruptured bullae results in oozing and formation of yellow crusts.

These lesions usually found in moist, intertriginous areas such as the diaper area, axillae, and neck folds. Systemic symptoms may include fever, generalized weakness and diarrhea, and these symptoms are usually absent in impetigo contagiosa. Regional lymphadenopathy may be a common occurrence in impetigo contagiosa but it is rare in patients with bullous impetigo. The disease is mostly self-limited and symptoms resolve without scarring within few weeks.

Differential Diagnosis

  • Herpes Simplex Virus
  • Varicella
  • Atopic Dermatitis
  • Contact DermatitisInsect Bites
  • Scabies
  • Inflammatory Superficial Fungal Infection
  • Insect Bites
  • Acute pustular Psoriasis
  • Primary cutaneous listeriosis
  • Sweet's Syndrome
  • Pemphigous foliaceus
  • Ecthyma
  • Discoid Lupus Erythematosus

Impetigo treatment

The goal of treatment in bullous impetigo is to relieve the discomfort, eradicate the infection, prevent spread of the infection to others, and to prevent recurrence. Treatment may involve use of topical therapy alone or a combination of systemic and topical therapies. The infected crusts and debris have to be removed with gentle abrasion using antiseptic soap and water. Deep abrasive scrubbing is not needed. Subsequently, application of topical antibiotics mupirocin and fusidic acid for five to seven days are safe and effective in mild cases of impetigo.

Systemic antibiotics are preferred when the lesions are more extensive. Oral flucloxacillin is considered the treatment of choice for impetigo. Other antibiotics such as macrolides, cephalosporins, and co-amoxiclav are also found to be effective. If oral antibiotics are required, the recommended first line of treatment is a seven day course of flucloxacillin.

In addition, application of topical antiseptics can be used as adjuncts to antibiotics as they help to soften the crusts and clear exudate in mild impetigo. Further, follow-up is important to ensure complete clearing of lesions. Lesions usually heal without scarring in two to three weeks, with early and appropriate therapy. Nevertheless, the presence of a pre-existing skin infection may prolong the course of the disease. If the lesions have not resolved within seven to ten days, culture from the lesions has to be taken in order to find resistant organisms.

Impetigo complications prevention and natural herbal remedies

The following are possible complications which may occur from bullous impetigo:

  • Meningitis or sepsis (infants)
  • Poststreptococcal glomerulonephritis (all age groups)
  • Ecthyma (deep or invasive impetigo)
  • Erysipelas
  • Cellulitis
  • Septicemia
  • Lymphadenitis
  • Osteomyelitis
  • Septic arthritis
  • Pneumonia


The following measures may help to prevent bullous impetigo:

  • Good hygiene practices such as regular hand washing.
  • Regularly washing areas of minor skin trauma with soap and water. 
  • Avoiding overcrowded living conditions.
  • Covering the lesions with appropriate dressing. 
  • Avoiding contact with the infected child and his or her belongings.
  • Affected children should not return to school or daycare centers before the lesions clear.

Natural Herbal Remedies

The following home remedies can be tried as an alternative to medical treatment in mild cases of impetigo:

  1. Application of crushed garlic on the affected area acts as a good antiseptic. Consumption of two or three garlic cloves on a regular basis helps in the healing process.
  2. Application of thyme lavender or bergamot oils may help to prevent the scarring that may result from skin infections.
  3. Regular application of aloe vera gel four to five times a day.
  4. Application of olive oil, garlic oil, and tea tree oil.
  5. Apple cider vinegar diluted with 4 parts of water can be used to clean the affected area in order to remove impetigo scabs.

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