Case Discussion

Impetigo (or pyoderma) has traditionally been classified into 2 clinical forms:
- Bullous and Nonbullous

Nonbullous Impetigo

- More common form and is a superficial infection of the skin that appears first as a discrete papulovesicular lesion
surrounded by a localized area of redness.
- The vesicles rapidly become purulent and covered with a thick, confluent, amber-colored crust that gives the appearance of
having been stuck onto the skin.
- The lesions may occur anywhere but are most common on the face and extremities.
- If untreated, nonbullous impetigo is a mild but chronic illness, often spreading to other parts of the body, but occasionally
self-limited.
- Regional lymphadenitis is common.
- Nonbullous impetigo is generally not accompanied by fever or other systemic signs or symptoms.
- Impetiginized excoriations around the nares are seen with active GAS infections of the nasopharynx particularly in young
children. However, impetigo is not usually associated with an overt streptococcal infection of the upper respiratory tract.

Bullous Impetigo
- less common and occurs most often in neonates and young infants.
- It is characterized by flaccid, transparent bullae usually <3 cm in diameter on previously untraumatized skin. The usual
distribution involves the face, buttocks, trunk, and perineum.
- Staphylococcus aureus has traditionally been accepted as the sole pathogen responsible for bullous impetigo, there has
been confusion about the organisms responsible for nonbullous impetigo.
- In most episodes of nonbullous impetigo, either GAS or S. aureus, or both, is isolated.

Epidemiology

- Occurs more frequently in tropical climates and at lower altitudes. Warm, humid conditions combined with frequent
cutaneous disruption via biting insects favor its development throughout the year in tropical climates. Crowded conditions
or poor hygiene also promote impetigo.
- Can affect people of all races. Overall, the incidence in males and that in females are equal; in adults, however, impetigo is
more common in men. Impetigo occurs in individuals of all ages but is most common in children 2-5 years of age. Rapid
dissemination can occur through day care centers, nurseries, and grade schools.
- Bullous impetigo is most common in neonates and infants; 90% of cases occur in children younger than 2 years. If
premature rupture of membranes occurs during labor, lesions of impetigo may be present at birth.

Etiology

- Impetigo is caused by bacterial infection.

- Both S aureus and GABHS cause non-bullous impetigo; S aureus accounts for approximately 80% of cases, GABHS accounts
for 10% of cases, and both organisms are recovered in 10% of cases. Bullous impetigo is caused almost exclusively by S
aureus.
Pathology

Work-ups

- Diagnosis of impetigo is usually based solely on history and clinical appearance. Bacterial culture and sensitivity are
recommended:
- (1) to identify possible methicillin-resistant Staphylococcus aureus (MRSA),
- (2) if an outbreak of impetigo has occurred,
- or (3) if poststreptococcal glomerulonephritis is present

Management

- Treatment of impetigo typically involves local wound care along with antibiotic therapy.
- Antibiotic therapy for impetigo may be with a topical agent alone or a combination of systemic and topical agents.
- Gentle cleansing, removal of the honey-colored crusts of nonbullous impetigo using antibacterial soap and a washcloth, and
frequent application of wet dressings to areas affected by lesions are recommended.
- Good hygiene with antibacterial washes, such as chlorhexidine or sodium hypochlorite baths, may prevent the transmission
of impetigo and prevent recurrences, but the efficacy of this has not been proven.
- For antibiotic therapy, the chosen agent must provide coverage against both Staphylococcus aureus and Streptococcus
pyogenes.
- Treat traumatized skin with mupirocin because this has been shown to decrease the rates of impetigo spread.
- Treat preexisting underlying skin diseases, such as atopic dermatitis. Antihistamines and topical steroids help decrease
scratching. Treating the underlying disease has also been shown to decrease the pathogen count on the skin
Prognosis
- Cure rate of complete cure and recovery of the infected area is extremely high
- Sores of impetigo heal slowly and seldom scar
- Condition often comes back in young children

Complications
- Post-streptococcal glomerulonephritis
- Staphylococcal Scalded Skin Syndrome (very rare)

Prevention
- Children with impetigo should avoid close contact with other children if possible.
- Current recommendations call for the exclusion of children with impetigo from school or day care for 24 hours after the
initiation of antibiotics.
- If S aureus is documented to be the etiology, exclusion from school or day care is not necessary.
- Inspect household members for impetiginous lesions.
- With neonatal impetigo, also evaluate hospital nursery staff and household members for pyodermas or asymptomatic
bacterial carrier states.
- Failure to treat other infected persons may result in continued transmission.
- Teach good personal hygiene.
- Keep nails short and clean and wash hands frequently with antibacterial soap and water or waterless antibacterial
cleansers.
- Advise patients about improving environmental conditions through the addition of air conditioning and by keeping
surroundings clean.

Sources:
Nelson’s Text book of pediatrics 20th edition and Medscape: Impetigo