Impetigo
Impetigo is a superficial bacterial infection of the skin. It is caused by staphylococci and streptococci — bacteria that sit quite peacefully on the skin…
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Medicines commonly prescribed for Impetigo
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: CREAM, 20 mg/gActive substance: fusidic acidManufacturer: Redox Farma S.L.U.Prescription requiredDosage form: CREAM, 2%Active substance: fusidic acidManufacturer: Isdin S.A.Prescription requiredDosage form: CREAM, 2 %Active substance: fusidic acidManufacturer: Laboratorios Leo Pharma S.A.Prescription required
Impetigo is a superficial bacterial infection of the skin. It is caused by staphylococci and streptococci — bacteria that sit quite peacefully on the skin and inside the nose of a great many healthy people and only cause trouble once they get through the skin barrier by way of a break. It is commonest in toddlers and children in their first school years, though anyone of any age can catch it. It is highly contagious and travels easily through a household or a nursery class, but with treatment it settles within days and in the great majority of cases leaves nothing behind.
What it looks like on the skin
Impetigo starts wherever the skin is already broken: around the nose and mouth, on the chin, on hands and legs, on a scratch, an insect bite, a graze or a patch that has been scratched.
- First a small reddish spot appears, and on it a thin-walled blister quickly rises.
- The blister bursts almost at once, leaving a moist surface that dries into a crust of a characteristic honey-yellow colour. That golden crust is the most recognisable feature of the illness.
- The patches itch and slowly enlarge, and new ones crop up beside them: by scratching, a person carries the bacteria to fresh areas of their own skin.
- The nearest lymph glands may swell.
- There is usually little or no pain, and the temperature is generally normal.
On brown and black skin the redness is hard to see, so going by colour is pointless. Look at everything else instead: blisters, weeping areas, crusts, swelling, and how the surface of the skin feels to the touch.
The blistering form deserves a mention of its own. Here large, slack blisters with cloudy contents develop, most often on the trunk, in the armpits and groin and in skin folds. They last longer and, once open, leave a flat moist area with a collar of lifted skin at the edge. This form is particularly typical of babies and always needs a doctor to look at it.
Healing leaves no scars unless the patches have been scratched into deep sores. Skin that is temporarily darker or lighter where the crusts were is normal, and it evens out over weeks or months.
What it gets mistaken for
Several skin conditions look alike, and getting the identification wrong changes the treatment completely.
- Cold sores. Small blisters in a tight cluster in one and the same spot, often preceded a day earlier by tingling and burning, and recurring in that same place time after time. Impetigo is not tied to a single site like that.
- Chickenpox. Blisters come out in waves all over the body, scalp included, with fever and a general feeling of illness.
- Shingles. The rash follows a band down one side of the body and is distinctly painful, often before any blisters show.
- Atopic eczema. Dryness, scaling, cracks, stubborn itch and a course that runs for years in flares. But impetigo settles on eczema more readily than anywhere else, so one does not rule out the other: if long-standing eczema suddenly starts weeping and crusting yellow, an infection has joined in.
- Scabies. Itching that is unbearable at night, burrows between the fingers and at the wrists, and other people in the house scratching too.
- Fungal infection of the skin. A round patch with a raised scaly edge and a clearer centre.
One combination must not be left to wait. If someone with eczema suddenly comes out in a mass of identical small blisters with a dimple in the middle, the skin is painful, the temperature rises and they become unwell, this may be eczema herpeticum — herpes virus spreading across damaged skin. It moves quickly and is treated in hospital with antiviral medicines.
Where it comes from and how it spreads
The organisms behind impetigo are nothing exotic: they are present on the skin and in the nose of a large share of the population without giving any sign of themselves. The illness begins when they reach a place where the skin barrier is broken — a cut, an insect bite, a crack in eczema, a graze, a shaving nick, a scratch made because of scabies or head lice.
From there it spreads two ways. By direct skin-to-skin contact: hugs, children playing, wrestling and other contact sports. And through objects: shared towels, bedding, flannels, clothing, toys, gym mats and equipment. Crowding, heat and humidity all help it along.
When impetigo keeps coming back, the explanation is often that the bacteria are being carried in someone's nose — either the patient's own or that of a household member who feels perfectly well.
How it is treated
Treatment depends on how far things have spread.
- A few small patches are usually managed with something applied to the skin: an antiseptic or an antibiotic ointment. The course is short, but it has to be finished rather than stopped the moment the skin looks presentable.
- Before applying anything the crusts are softened with warm soapy water and lifted off gently: under a dry crust the medicine never reaches the bacteria.
- Antibiotics by mouth are needed when the patches are numerous or large, in the blistering form, in babies, where immunity is weakened, if there is fever and swollen glands, and also when treatment applied to the skin has achieved nothing over several days.
- What lies underneath is treated at the same time. Until eczema is under control and scabies has been cleared, impetigo will keep returning.
What not to do: fetch the antibiotic left over from last time out of the cupboard and dose yourself or your child with it. The wrong drug for the wrong length of time drags the illness out and breeds bacterial resistance — the very reason skin infections that used to be straightforward are becoming harder to cure.
When episodes keep repeating, the doctor takes a swab from the skin and from inside the nose to find out which organism is involved and what will treat it. That is also when a course to clear carriage is prescribed: antiseptic washes and nasal ointment, sometimes for the whole household at once.
When cream alone is not enough
Impetigo is usually harmless, but it has several ways of turning, and they are worth knowing about in advance.
See a doctor the same day if:
- the patient is a baby under a year old, and above all a newborn — treating that at home is not an option;
- a temperature develops, or there is listlessness and refusal of food and drink;
- redness spreads well beyond the crusts, the surrounding skin is hot, swollen and tender, or a streak runs up the arm or leg from the patch: that is how infection of the deeper layers of the skin begins;
- blisters enlarge rapidly, the skin peels away in sheets and hurts at the lightest touch — in small children this is a severe reaction to staphylococcal toxin, and it is treated in hospital;
- the patches are on the face near the eyes or cover a wide area;
- you are breastfeeding and the nipple or breast is affected;
- you have diabetes, take medicines that damp down immunity, or are having chemotherapy;
- after two or three days of treatment there is no improvement, or things have got worse.
Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine the single European number 112 answers) if pain in the area is far out of proportion to how the skin looks, a purple patch is visibly spreading, blisters with dark contents appear, there are areas of numb skin, violent shivering with a high temperature, or confusion. These are signs of a deep tissue infection that is rare but can threaten life within hours.
There is also a complication that hardly anyone is warned about. One to three weeks after impetigo caused by streptococcus, the kidneys are occasionally affected. Watch for urine the brown colour of meat washings, a marked drop in how much is passed, puffy eyelids and face in the morning, swollen legs, raised blood pressure and headache. That warrants seeing a doctor the same day even if the skin healed long ago: the link with a past skin infection is easily missed.
How to stop it spreading
A person is infectious for as long as the patches are weeping. Infectivity stops about forty-eight hours after treatment starts; without treatment, only once the crusts dry and drop off by themselves, which takes weeks.
- Stay at home for that period: a child does not go to nursery or school, and an adult stays off work if the job involves the public or food.
- Wash the patches with warm soapy water and pat them dry rather than rubbing.
- Towel, flannel and bedding for one person only. Change and wash them daily at a high temperature.
- Wash hands after every contact with the skin and always after applying the ointment.
- Try not to touch the patches or pick the crusts off. Cut children's nails short and cover the area with a dressing where that is practical.
- Wash toys with detergent; soft toys go in the machine.
- Do not cook for other people, do not use the swimming pool or the gym, avoid contact sports, and do not share razors or make-up.
- Keep away from newborn babies and from anyone with eczema, diabetes or weakened immunity — for them this infection is far more dangerous.
How to avoid repeat episodes
Impetigo nearly always settles on skin that is already damaged, so prevention is about skin care rather than about fighting germs.
- Wash any scratch, graze, cut or bite with soap and water and cover it where you can.
- Keep eczema under control: dry, cracked skin is an open door. Moisturising regularly does more to prevent impetigo than any antiseptic.
- Do not let scabies or head lice run on: they make people scratch themselves raw.
- Everyone in the house should have their own towel, and bedding should be changed often.
- Shower after contact-sport training, and wipe down mats and equipment.
- If episodes recur several times a year, mention it: it is worth checking the family for carriage.
Online consultation
Impetigo is exactly the sort of problem a photograph shows well. In an online consultation the doctor will look at pictures of the patches and ask where and when it all started, what the skin was like beforehand, whether there is itching, fever or swollen glands, and who else at home has caught it. They will help you tell impetigo apart from cold sores, eczema, scabies and fungal infection, explain whether treatment applied to the skin will do or antibiotics by mouth are needed, and check separately for the signs that call for a face-to-face examination or an ambulance. They will also cover the practical side: how to deal with the crusts, when a child can go back to nursery or school, what everyone else in the house should do, and how not to end up in the same position a month later.
This material is for information only and does not replace medical advice.
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