Impetigo PDF

6/20/2016
Impetigo
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Impetigo
Author
LarryMBaddour,MD,FIDSA
SectionEditors
DanielJSexton,MD
SheldonLKaplan,MD
TedRosen,MD
DeputyEditor
AbenaOOfori,MD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2016.|Thistopiclastupdated:Feb26,2015.
INTRODUCTIONImpetigoisacontagioussuperficialbacterialinfectionobservedmostfrequentlyinchildren.Itmay
beclassifiedasprimaryimpetigo(directbacterialinvasionofpreviouslynormalskin)(picture1AC)orsecondaryimpetigo
(infectionatsitesofminorskintraumasuchasabrasions,minortrauma,andinsectbites,orunderlyingconditionssuchas
eczema(picture2)).Pyodermaandimpetigocontagiosaaresometimesusedassynonymsforprimaryimpetigo.The
occurrenceofsecondaryimpetigoissometimesreferredtoas"impetiginization."
Impetigoismostfrequentlyobservedinchildrenagestwotofiveyears,althougholderchildrenofanyageandadultsmay
alsobeaffected.Theinfectionusuallyoccursinwarm,humidconditionsandiseasilyspreadamongindividualsinclose
contactriskfactorsincludepoverty,crowding,poorhygiene,andunderlyingscabies[1].CarriageofgroupA
Streptococcus(GAS)andStaphylococcusaureuspredisposestosubsequentimpetigo[2].
CLINICALMANIFESTATIONSVariantsofimpetigoincludenonbullousimpetigo,bullousimpetigo,andecthyma.
Poststreptococcalglomerulonephritisandrheumaticfeverfollowingimpetigohavealsobeendescribed.(See
"Poststreptococcalglomerulonephritis"and"Acuterheumaticfever:Clinicalmanifestationsanddiagnosis".)
NonbullousimpetigoNonbullousimpetigoisthemostcommonformofimpetigo.Lesionsbeginaspapulesthat
progresstovesiclessurroundedbyerythema.Subsequentlytheybecomepustulesthatenlargeandrapidlybreakdownto
formthick,adherentcrustswithacharacteristicgoldenappearancethisevolutionusuallyoccursoveraboutoneweek
(picture1AB,1DE).Lesionsusuallyinvolvethefaceandextremities.Multiplelesionsmaydevelopbuttendtoremain
welllocalized.Regionallymphadenitismayoccur,althoughsystemicsymptomsareusuallyabsent.
BullousimpetigoBullousimpetigoisaformofimpetigoseenprimarilyinyoungchildreninwhichthevesiclesenlarge
toformflaccidbullaewithclearyellowfluid,whichlaterbecomesdarkerandmoreturbidrupturedbullaeleaveathin
browncrust(picture1C,1FG)[3,4].Usuallytherearefewerlesionsthaninnonbullousimpetigo,andthetrunkismore
frequentlyaffected.Bullousimpetigoinanadultwithappropriatedemographicriskfactorsshouldpromptaninvestigation
forpreviouslyundiagnosedhumanimmunodeficiencyvirus(HIV)infection[5].
BullousimpetigoisduetostrainsofS.aureusthatproduceexfoliativetoxinA,atoxinthatcauseslossofcelladhesionin
thesuperficialepidermisbytargetingtheproteindesmoglein1[6].Thismechanismisrelatedtothepathophysiologyof
pemphigus,inwhichautoantibodiesaredirectedagainstthesameprotein[7].(See"Pathogenesis,clinicalmanifestations,
anddiagnosisofpemphigus".)
EcthymaEcthymaisanulcerativeformofimpetigoinwhichthelesionsextendthroughtheepidermisanddeepintothe
dermis.Theyconsistof"punchedout"ulcerscoveredwithyellowcrustsurroundedbyraisedviolaceousmargins(picture
3AB)[8].
POSTINFECTIOUSSEQUELAE
PoststreptococcalglomerulonephritisPoststreptococcalglomerulonephritisisapotentialcomplicationof
streptococcalimpetigothatmostoftenoccurswithinonetotwoweeksfollowinginfection[9].Commonclinicalfindings
includeedema,hypertension,fever,andhematuria[10,11].Itisunclearwhetherantimicrobialtherapyforimpetigoreduces
theriskofpoststreptococcalglomerulonephritis[12].(See"Poststreptococcalglomerulonephritis".)
RheumaticfeverInAustralianaboriginalcommunities,whereacuterheumaticfeverishyperendemic,lowratesof
streptococcalpharyngitisandhighratesofimpetigohavebeenobserved[13].Observershavehypothesizedthat
streptococcalskininfectionssuchasimpetigomaybeprotectiveagainstpharyngitisbutmaybefollowedbysequelae
suchasacuterheumaticfever.(See"Acuterheumaticfever:Clinicalmanifestationsanddiagnosis".)
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MICROBIOLOGYTheprincipalpathogenisS.aureus.Betahemolyticstreptococci(primarilygroupA,butoccasionally
otherserogroupssuchasCandG)accountforaminorityofcases,eitheraloneorincombinationwithS.aureus[1416].
TherelativefrequencyofS.aureusinfectionshaschangedwithtime.Itwaspredominantinthe1940sand1950s,after
whichgroupAstreptococcibecamemoreprevalent.Sincethe1990s,S.aureushasbecomemorecommonagain[17].
MethicillinresistantS.aureusisdetectedinsomecasesofimpetigo.InaChinesestudythatinvestigatedthe
antimicrobialsusceptibilityof984S.aureusisolatestakenfromsitesofimpetigoinchildren,communityacquiredMRSA
wasidentifiedin1percent[18].OtherstudieshavefoundhigherratesofMRSAinimpetigo[1921].Asanexample,a
Japanesestudyof136S.aureusisolatesfromchildrenwithimpetigofoundcommunityacquiredMRSAin10percent[19].
BullousimpetigoiscausedbystrainsofS.aureusthatproduceatoxincausingcleavageinthesuperficialskinlayer(see
'Bullousimpetigo'above).EcthymaisduetogroupA,betahemolyticStreptococcus(Streptococcuspyogenes).
Streptococcalcolonizationofintactskinprecedesinoculationviabreachesintheskinbacteriamaybesubsequently
transferredfromtheskintotheupperrespiratorytract.ThegroupAStreptococcusvirulencefactor,emmprotein,canbe
encodedbyoneoffivechromosomepatternsofemmgenes(denotedAthroughE)[22].Pharyngealstrainsusuallyhave
patternsAC,whilenearlyallimpetigostrainshavepatternsDorE[23].Theimpetigostrainspatternsarerarelyobserved
amonginvasiveclinicalisolates[24].
DIAGNOSISThediagnosisofimpetigooftencanbemadeonthebasisofclinicalmanifestations.Thekeyclinical
findingsofnonbullousimpetigo,bullousimpetigo,andecthymainclude:
NonbullousimpetigoPapules,vesicles,andpustulesthatrapidlybreakdowntoformgoldenadherentcrusts
oftenlocatedonthefaceorextremities(picture1AB,1DE)
BullousimpetigoFlaccid,fluidfilledbullaethatruptureandleaveathinbrowncrustoftenlocatedonthetrunk
(picture1C,1F)
Ecthyma"Punchedout"ulcerswithoverlyingcrustsandraisedviolaceousborders(picture3AB)
AGramstainandcultureofpusorexudateisrecommendedtoidentifywhetherS.aureusand/orabetahemolytic
Streptococcusisthecause.However,treatmentmaybeinitiatedwithoutthesestudiesinpatientswithtypicalclinical
presentations[25].
SerologictestingforstreptococcalantibodiesisnotusefulforthediagnosisofimpetigotheantistreptolysinO(ASO)
responseisweak,likelybecauseskinlipidssuppressstreptolysinOresponse[2628].AntideoxyribonucleaseB(anti
DNaseB)andantihyaluronidase(AHT)responsearemorereliablethantheASOresponsefollowinggroupA
Streptococcus(GAS)skininfections.However,serologictestingcanbehelpfulinthesettingofimpetigowithsubsequent
presumedpoststreptococcalglomerulonephritis.
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisofimpetigodiffersbasedupontheclinicalpresentation.Gram
stainandcultureareusefulforconfirmingtheetiologicdiagnosis.(See'Microbiology'above.)
NonbullousimpetigoSkinconditionsthatmaysharefeatureswithnonbullousimpetigoincludeavarietyof
inflammatoryconditionsthatmaypresentwithlocalizedareasofinflammation.Examplesincludecontactdermatitis
(picture4AB),tineainfection(picture5AB),andeczemaherpeticumandotherherpessimplexvirusinfections
(picture6AC).Recognitionofthecharacteristicgoldencrustshouldraisesuspicionforimpetigo.
BullousimpetigoBullousimpetigoshouldbedifferentiatedfromotherblisteringskinconditions.Examplesinclude
autoimmuneblisteringdiseases(table1),acutecontactdermatitis(picture7),bullousdrugeruptions,burns,bullous
insectbitereactions(picture8AB),varicella(picture9),andsubcornealpustulardermatosis(picture10).The
progressionfrombullaetoerosionswithperipheralcrustischaracteristicofbullousimpetigo.(See"Approachtothe
patientwithcutaneousblisters".)
EcthymaThedifferentialdiagnosisofecthymaoftenincludesotherconditionsthatmaycauselocalizedulcers,
suchasmycobacterialordeepfungalinfections(picture11AB)orpyodermagangrenosum(picture12AB).Ecthyma
shouldnotbeconfusedwithecthymagangrenosum,apotentiallylifethreateningskinconditionthatoccursin
patientswithpseudomonalbacteremia.Inecthymagangrenosum,painlesserythematousorpurpuricmaculesrapidly
evolveintohemorrhagicvesiclesorbullaethatsubsequentlyrupturetoleaveanulcerwithnecroticblackeschar
(picture13AB).Unlikeecthyma,patientswithecthymagangrenosumareusuallysystemicallyill.(See
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"Pseudomonasaeruginosaskin,softtissue,andboneinfections",sectionon'EcthymaGangrenosum'.)
TREATMENTTreatmentofimpetigoisimportantforreducingspreadofinfection,hasteningtheresolutionof
discomfort,andimprovingcosmeticappearance[29].Bullousandnonbullousimpetigocanbetreatedwitheithertopicalor
oraltherapy.Topicaltherapyisusedforpatientswithlimitedskininvolvement,whereasoraltherapyisrecommendedfor
patientswithnumerouslesions[25].Unlikeimpetigo,ecthymashouldalwaysbetreatedwithoraltherapy[25].In
healthcaresettings,contactprecautionstoavoidspreadofimpetigoareindicateduntil24hoursafterthestartofantibiotic
therapy[30].
LimitedimpetigoTopicaltherapyforimpetigoshouldbeadministerediftherearealimitednumberoflesions.
TopicaltherapyBenefitsoftopicaltherapyincludefewersideeffectsandlowerriskforcontributingtobacterial
resistancecomparedwithoraltherapy[29].Mupirocinandretapamulinareprobablyequallyeffectivetopicaltherapies
[29,3139].Mupirocinisappliedthreetimesdailyandretapamulinisappliedtwicedaily.Therecommendedlengthof
treatmentisfivedays[25].
Topicalfusidicacidcanbeeffectiveforimpetigohowever,evidenceforincreasingresistanceofS.aureustofusidicacid
inlocationswheretopicalfusidicaciduseiscommonhasmadeitalessfavorableoptionfortherapy[40].Fusidicacidis
notavailableintheUnitedStates.
Althoughthecomponentsofoverthecountertripleantibioticointments(consistingofbacitracinneomycinpolymyxinB)do
havesomeactivityagainsttheorganismscausingimpetigo,theymaynotbeaseffectivefortreatment[33].Therefore,
treatmentofimpetigowiththeseagentsisnotrecommended.Bacitracinandneomycincanalsocausecontactdermatitis.
Inrarecases,bacitracinhasbeenassociatedwithallergicanaphylactoidreactions[41].
ExtensiveimpetigoandecthymaOraltherapyshouldbeadministeredtopatientswithnumerousimpetigolesionsor
ecthyma.
SystemicantibioticsUnlessculturesrevealonlystreptococci,theoralantibioticprescribedforimpetigoand
ecthymashouldbeeffectiveforthetreatmentofbothS.aureusandstreptococcalinfections(table2)(see'Streptococcal
impetigo'below).DicloxacillinandcephalexinareappropriatetreatmentsbecauseS.aureusisolatesfromimpetigoand
ecthymaareusuallysusceptibletomethicillin[25].Althougherythromycinandclindamycincanalsotreatimpetigo,some
strainsofS.aureusandStreptococcuspyogenesmayberesistanttothesetherapies[25].Therapeuticoptionsfor
impetigoareprovidedinatable(table2).Asevendaycourseoforalantibiotictreatmentisrecommended[25].
SpecialcasesCertainscenarioswarrantadjustmentsintheapproachtotreatment.
StreptococcalimpetigoIfonlystreptococciaredetectedinextensiveimpetigoorecthyma,oralpenicillinisthe
preferredtherapy[25].Limitedstreptococcalimpetigocanbetreatedwithtopicaltherapy.(See'Limitedimpetigo'above.)
Althoughtheefficacyoftrimethoprimsulfamethoxazoleforstreptococcalinfectionshasbeenperceivedasuncertain,the
findingsofanopenlabel,assessorblindedrandomizedtrialperformedin508childreninremoteAustraliasuggestthatoral
trimethoprimsulfamethoxazoleisaneffectivealternativetoinjectablepenicillinforthetreatmentofimpetigoinwhich
streptococcalinfectionispresent[42].Inthetrial,threeorfivedaycoursesoforaltrimethoprimsulfamethoxazoleanda
singleinjectionofbenzathinebenzylpenicillinweresimilarlyeffectiveforimprovingorhealingimpetigowithinsevendays.
NinetypercentofchildreninthetrialwereculturepositiveforS.pyogeneswithorwithoutconcomitantS.aureusinfection.
AlthoughnotafirstlinetreatmentfornonmethicillinresistantS.aureusimpetigo,ashortcourseoforaltrimethoprim
sulfamethoxazolemayrepresentaninexpensiveoralalternativeforstaphylococcalandstreptococcalimpetigoinresource
limitedsettings.
MRSAimpetigoPatientswithsuspectedorconfirmedmethicillinresistantS.aureus(MRSA)infectionscanbe
treatedwithdoxycycline,clindamycin,ortrimethoprimsulfamethoxazole,providedtheisolateissusceptible(table2).Of
note,childreneightyearsofageandundershouldnotbetreatedwithdoxycyclinebecauseofthepotentialfordrug
inducedtoothdiscoloration.(See"MethicillinresistantStaphylococcusaureus(MRSA)inadults:Treatmentofskinand
softtissueinfections".)
FluoroquinolonesshouldNOTbeusedtotreatimpetigo,asMRSAresistancetothisclassiswidespreadandresistance
candevelopontherapy.(See"MethicillinresistantStaphylococcusaureus(MRSA)inadults:Treatmentofskinandsoft
tissueinfections".)
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ImpetigooutbreaksOraltherapyratherthantopicaltherapyisrecommendedinoutbreaks,includingthose
complicatedbypoststreptococcalglomerulonephritis(table2)[25].
FollowupCrustedlesionscanbewashedgently.Handwashingisimportantforreducingspreadamongchildren,and
otherpreventivemeasuresemployedinreducingthespreadofstaphylococcimayalsobehelpful[43,44].(See"Methicillin
resistantStaphylococcusaureus(MRSA)inadults:Preventionandcontrol".)
Improvementinimpetigoshouldbenotedwithinasinglecourseofappropriateantibiotictreatment.Thepossibilityof
resistantpathogensoranincorrectdiagnosisshouldbeconsideredwhenlesionsfailtorespondtoantibiotictherapy.(See
'Differentialdiagnosis'above.)
ReturntoschoolChildrencanreturntoschool24hoursafterbeginninganeffectiveantimicrobialtherapy.Draining
lesionsshouldbekeptcovered.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and"Beyond
theBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereadinglevel,and
theyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebestfor
patientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducation
piecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevel
andarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicsto
yourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon"patientinfo"andthe
keyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Impetigo(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Impetigo(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Impetigoisacontagioussuperficialbacterialinfectionmanifestingonthefaceandextremitieswithlesionsthat
progressfrompapulestovesicles,pustules,andcrusts(picture1AB,1D).Lesscommonmanifestationsinclude
bullousimpetigoandecthyma(picture1C,1F,3AB).Impetigomaybefollowedbypoststreptococcal
glomerulonephritisorrheumaticfever.(See'Clinicalmanifestations'above.)
TheprincipalpathogenisS.aureus.Incontrasttoskinabscess,communityacquiredmethicillinresistant
Staphylococcusaureus(CAMRSA)isanuncommoncauseofimpetigo.Betahemolyticstreptococci(primarilygroup
A,butoccasionallyotherserogroupssuchasCandG)causeaminorityofcases,eitheraloneorincombinationwith
S.aureus.(See'Microbiology'above.)
Formanagementofimpetigowithasmallnumberoflesions,werecommendtreatmentwithtopicaltherapyrather
thanoraltherapy(Grade1A).Topicalmupirocinandtopicalretapamulinareoptionsfortopicaltherapy.Mupirocinis
appliedthreetimesdailyandretapamulinisappliedtwicedaily.Therecommendeddurationoftreatmentforthese
medicationsisfivedays.(See'Treatment'above.)
Forpatientswithnumerousimpetigolesions,werecommendtreatmentwithoralantibiotictherapy(Grade1B).The
antibioticselectedshouldbeeffectiveforthetreatmentofbothS.aureusandstreptococcalinfectionsdicloxacillin
andcephalexinareappropriatetreatments(table2).Oralantibiotictherapyshouldbegivenforsevendays.Inthe
settingofsuspectedCAMRSA,appropriatechoicesincludedoxycycline,clindamycin,ortrimethoprim
sulfamethoxazole(table2).(See'Treatment'above.)
Handwashingisimportantforreducingspreadamongchildren,andotherpreventivemeasuresemployedinreducing
thespreadofstaphylococcimayalsobehelpful.(See"MethicillinresistantStaphylococcusaureus(MRSA)in
adults:Preventionandcontrol".)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic7655Version19.0
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GRAPHICS
Nonbullousimpetigo
Perinasalerythema,erosions,andcrustsinachildwithnonbullousimpetigo.
Reproducedwithpermissionfrom:www.visualdx.com.Copyright2014LogicalImages,Inc.
Graphic96268Version1.0
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Nonbullousimpetigo
Goldcoloredcrustsonthechinofapatientwithnonbullousimpetigo.
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Bullousimpetigo
Bullae,erosions,andcrustsinapatientwithbullousimpetigoontheneck.
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Secondaryimpetigo(impetiginization)
Nonbullousimpetigoatsitesofskininjuryinapatientwithaskinpickingdisorder.
CourtesyofTedRosen,MD.
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Impetigo
"Honeycrusted"plaquesonthefaceofachildwithimpetigo.
Reproducedwithpermissionfrom:Stedman'sMedicalDictionary.Copyright
2008LippincottWilliams&Wilkins.
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Impetigovesiculopustules
Impetigovesiculopustuleswithcrusting.
CourtesyofLarryMBaddour,MD.
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Bullousimpetigo
Crustsatthesitesofrupturedbullaeinbullousimpetigo.
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Bullousimpetigo
Multipleerosionswithcrustinachildwithbullousimpetigo.
Reproducedwithpermissionfrom:www.visualdx.com.CopyrightLogicalImages,Inc.
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Ecthyma
Multipleulcerswithadherentcrusts.
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Ecthyma
Ulcerwithadherentcrust.
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Contactdermatitisoftheperiorbitalskin
Intenseerythemaandedemawithvesiculationinthispatientwith
allergiccontactdermatitisoftheeyelids.
Reproducedwithpermissionfrom:www.visualdx.com.CopyrightLogical
Images,Inc.
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Impetigo
Acuteallergiccontactdermatitis
Discreteandconfluentred,scaly,weepy,crustedpapulesand
plaques.A25yearoldwomanconsultedadermatologistforanacute
eczematousdermatitisonherhead,neckandshoulders.Theeruption
appearedfivedaysaftershehadblackhairdyeappliedtoherhairat
thehairdresser.Patchtestswerepositiveforparaphenylenediamine.
Paraphenylenediamineisadarkdyeusedinalmostallpermanent
hairdyesandsomesemipermanenthaircoloring.Itisapotent
allergenthattriggerssevereacutecontactdermatitisinsensitized
individuals.
CopyrightEricEhrsam,MD,Dermatlashttp://www.dermatlas.org.
6/20/2016
Impetigo
Tineabarbae
Follicularpustulesandcrustedlesionsinapatientwithtineabarbae.
6/20/2016
Impetigo
Tineabarbae
Largeerythematouspapulopustularlesionsinthebeardareaofapatientwith
Trichophytoninfection.
6/20/2016
Impetigo
Eczemaherpeticum
Hemorrhagiccrustsandvesiclesduetoherpessimplexvirusinfection
arepresentonthefaceofthisinfantwithunderlyingatopic
dermatitis.
Reproducedwithpermissionfrom:FleisherGR,LudwigS,BaskinMN.Atlasof
PediatricEmergencyMedicine,LippincottWilliams&Wilkins,Philadelphia
2004.Copyright2004LippincottWilliams&Wilkins.
6/20/2016
Impetigo
Eczemaherpeticum
Hemorrhagiccrustsandvesiclesduetoherpessimplexvirusinfection
arepresentonthehandofthisinfantwithunderlyingatopic
dermatitis.
Reproducedwithpermissionfrom:FleisherGR,LudwigS,BaskinMN.Atlasof
PediatricEmergencyMedicine,LippincottWilliams&Wilkins,Philadelphia
2004.Copyright2004LippincottWilliams&Wilkins.
6/20/2016
Impetigo
Herpessimplexlabialis
Groupedvesiclesareevidentonthelowervermilionborder.
Reproducedwithpermissionfrom:BickleyLS,SzilagyiP.Bates'GuidetoPhysical
ExaminationandHistoryTaking,EighthEdition.Philadelphia:LippincottWilliams&
Wilkins,2003.Copyright2003LippincottWilliams&Wilkins.
6/20/2016
Impetigo
Autoimmunemucocutaneousblisteringdiseases
Pemphigoid
Bullouspemphigoid
Mucousmembranepemphigoid
Pemphigoidgestationis
Antilaminin332pemphigoid(antiepiligrincicatricialpemphigoid)
Antilaminingamma1pemphigoid
Otherpemphigoidvariants
LinearIgAdisease
LinearIgAbullousdermatosis
Chronicbullousdiseaseofchildhood
Pemphigus
Pemphigusvulgaris
Pemphigusvegetans
Pemphigusherpetiformis
Pemphigusfoliaceus
Pemphiguserythematosus
Fogoselvagem
Paraneoplasticpemphigus
IgApemphigus
Subcornealpustulardermatosis
IntraepidermalneutrophilicIgAdermatosis
Bullouslupuserythematosus
Dermatitisherpetiformis
Epidermolysisbullosaacquisita
6/20/2016
Impetigo
Allergiccontactdermatitis
Vesiclesandbullaedevelopedonthevolarforearmafterapplicationof
perfume.
Reproducedwithpermissionfrom:ElderAD,ElenitsasR,JohnsonBL,etal.Synopsis
andAtlasofLever'sHistopathologyoftheSkin,LippincottWilliams&Wilkins,
Philadelphia1999.Copyright1999LippincottWilliams&Wilkins.
6/20/2016
Impetigo
Bullousarthropodbite
Multipleerythematouspapulesconsistentwitharthropodbitesarepresenton
thefoot.Anintact,fluidfilledbullaispresentatthesiteofonelesion.
6/20/2016
Impetigo
Bullousarthropod(insect)bite
Abullaispresentinthesiteofaninsectbite.
6/20/2016
Impetigo
Chickenpox(varicellazosterinfection)
Numerousvesicles,someofwhicharehemorrhagic,onthefaceofachildwithchickenpox.
6/20/2016
Impetigo
Subcornealpustulardermatosis(Sneddon
Wilkinsondisease)
Multipleflaccidpustulesandcrustedplaquesarepresent.
Images,Inc.
6/20/2016
Impetigo
Mycobacteriummarinuminfection
Ulcerativenodulesonthearm.
CourtesyofCharlesVSanders,MD.ReproducedwithpermissionfromTheSkin
andInfection:AColorAtlasandText.SandersCV,NesbittLTJr(Eds)
LippincottWilliams&Wilkins,Baltimore1995.p.145.
http://www.lww.com.bibliotecavirtual.udla.edu.ec
6/20/2016
Impetigo
Skinlesionssporotrichosis
Courtesyofwww.doctorfungus.org.Copyright2006.
6/20/2016
Impetigo
Pyodermagangrenosum
Apurulentulcerispresentontheextremity.
6/20/2016
Impetigo
Pyodermagangrenosum
Thispurulentulcerwitharaggedandviolaceousborderisconsistent
withpyodermagangrenosum.
Images,Inc.
6/20/2016
Impetigo
Ecthymagangrenosum
Retiformpurpuriclesionsinapatientwithecthymagangrenosum.
6/20/2016
Impetigo
Ecthymagangrenosum
Necroticescharinecthymagangrenosum.
6/20/2016
Impetigo
Oralantibiotictherapyforimpetigo*
Medication
Adultdose
Childdose
Preferred
Dicloxacillinor
250to500mgfourtimesper
day
25to50mg/kgperdayinfour
divideddoses
Cephalexin
day
25to50mg/kgperdayinthree
tofourdivideddoses
Alternateforpenicillinandcephalosporinhypersensitivity
Erythromycin(base) or
250mgfourtimesperday
40mg/kgperdayinthreetofour
divideddoses
Clarithromycin
250mgtwiceperday
15mg/kgperdayintwodivided
doses
IfMRSAissuspectedorconfirmed
Clindamycin or
day
20mg/kgperdayinthreedivided
doses
Trimethoprim
sulfamethoxazoleor
1to2doublestrengthtablets
twiceperday
8to12mg/kg(trimethoprim)per
dayintwodivideddoses
Doxycycline
100mgtwiceperday
>8years:2to4mg/kgperday
intwodivideddoses
8years:notrecommended
Oralantibiotictherapyisindicatedforecthyma,impetigowithnumerouslesions,ortocontrol
transmissionduringoutbreaks.Asevendaycourseoforalantibiotictreatmentisrecommended.
MRSA:methicillinresistantStaphylococcusaureus.
*Doseslistedintableareforpatientswithnormalrenalfunctionthedosesofsomeagentsmustbeadjustedin
patientswithrenalinsufficiency.
Maximumsingledoseshouldnotexceeddoseforadults.
SomestrainsofStaphylococcusaureusandStreptococcuspyogenesmayberesistanttomacrolides.
PotentialcrossresistanceinerythromycinresistantisolatesinducibleresistanceinMRSA.
Asevendaycourseofdoxycyclineinachildolderthan8yearsisunlikelytocausetoothstaining.
CourtesyofauthorswithadditionaldatafromStevensDLetal.IDSAPracticeGuidelinesforSSTIs.CID2014
59:147.
6/20/2016
Impetigo
ContributorDisclosures
LarryMBaddour,MD,FIDSANothingtodisclose.DanielJSexton,MDGrant/Research/ClinicalTrialSupport:Centers
forDiseaseControlandPreventionNationalInstitutesofHealth[Healthcareepidemiology].Consultant/AdvisoryBoards:
Sterilis[Medicalwastedisposal].EquityOwnership/StockOptions:MagnoliaMedicalTechnologies[Medicaldiagnostics
(Bloodculturetechniques)].OtherFinancialInterest:Johnson&Johnson[Meshrelatedinfections].SheldonLKaplan,
MDGrant/Research/ClinicalTrialSupport:Pfizer[S.pneumoniae(PCV13,Linezolid)]Cubist[S.aureus(Tedizolid)]
ForestLab[Osteomyelitis(Ceftaroline)].Consultant/AdvisoryBoards:Pfizer[S.pneumoniae(PCV13,Linezolid)S.
aureus(vaccinedevelopment)]Theravance[S.aureus(Telavancin)].TedRosen,MDNothingtodisclose.AbenaO
Ofori,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedby
vettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.
AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
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