Oklahoma State Department of Health

01-2010 Revised

PHN GUIDELINE: IMPETIGO

I. DEFINITION:

Most common skin infection in children caused by invasion of the epidermis by pathogenic
Staphylococcus aureus or Streptococcus pyogenes, or a combination of these.

II. ETIOLOGY:

A. Pathogens are streptococci and/or staphylococci.

B. Direct contact with infected persons, contaminated fomites, or direct contact with an
asymptomatic carrier.

C. Nares are the major site of colonization; auto-infection is responsible for a significant
number of infections.

D. Insect bites, scabies, or other minor trauma to skin may precede infection.

E. Incubation period is typically 1-3 days for streptococcal disease and 4-10 days for
staphylococcal disease.

F. Communicable while purulent lesions are draining or while carrier state persists.

G. Peak incidence is late summer and early fall and occurs most commonly in young
children.

H. Recent trends have shown an increasing incidence of Staph. aureus-associated

impetigo. Common in sports because of the increased perspiration, body heat and
friction caused by sports equipment

I. Over the last decade, the emergence of community-acquired Methicillin resistant

Staphylococcus aureus (CA-MRSA) requires the provider to be mindful of community
acquired pathogens.

III. CLINICAL FEATURES (Diagnostic Criteria):

A. Signs and Symptoms:

1. Impetigo occurs in two clinical forms: Localized lymphadenopathy less common

than in non-bullous form.
a. Bullous (blistering) - Less common and is seen primarily in newborns
and infants.
b. Nonbullous (crusting) - Accounts for more than 70% of cases.

2. Physical symptoms uncommon, unless lesions widespread.

3. Superficial vesicles, containing serous fluid become purulent and surrounded by

erythema.

4. Multiple lesions are usually present and face and extremities are the most
common sites of involvement.

5. Pustules rupture, dry centrally, and form honey-colored crusts.

6. Lesions vary in size from a few millimeters to several centimeters.

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B. Differential Diagnosis:

1. Herpes Simplex
2. Chicken Pox
3. Ringworm
4. Allergic contact dermatitis
5. Burns
6. Erythema multiforme
7. Chronic bullous dermatosis

C. Complications:

Acute glomerulonephritis, osteomyelitis, pneumonia, septic arthritis, cellulitis, septicemia,

suppurative lymphadenitis, CA-MRSA.

IV. MANAGEMENT PLAN:

A. Treatment: FOR ISOLATED LESIONS ONLY

1. Soak and gently scrub lesions with warm water and antibacterial soap three
times a day to soften and remove crusts.

2. Trim fingernails to prevent further spread.

3. See PHN ORDER: IMPETIGO

4. Take precautions to prevent spread to other persons.

a. Teach good handwashing

b. Exclusion from school or daycare is not necessary if lesions can be
covered.

B. Consultation/Referral:

1. Refer to APN or physician if a lesion is on face, nose, or mouth or if more than a

single lesion is present. If multiple lesions are present which cannot be
adequately covered, exclude from school or daycare until 48 hours after initiation
of antibiotic treatment. Refer any infant, child, or adolescent suspected of having
CA-MRSA.

2. Refer if not improving in 3-5 days.

C. Follow-up:

Have the patient return in 3-5 days to determine response to treatment. If no response to
medication refer to physician.

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REFERENCES:
th
Nelson’s Textbook of Pediatrics, 18 Ed., 2007 (chapter 664)
th
Control of Communicable Diseases Manual, 18 Ed., 2004. American Public Health Association. pp. 498-
501, 507-514.
th
Wong’s Nursing Care of Infants and Children, 7 Ed. 2003. Wong, D.L. & Hockenberry, M.J. pp. 754-755.
Palavecino, E. “Community acquired Methicillin resistant Staphylococcus aureus infections” Clinics in
Laboratory Medicine 2004 vol. 24 pp 403-418.
Metry, Denise; Katta, R “New and emerging pediatric infections” Dermatologic Clinics 2003 vol 21 pp 269-
276.
MD Consult - Patient Education www.mdconsult.com

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PHN ORDER: IMPETIGO

FOR SINGLE LESIONS ONLY:

A. Soak and gently scrub lesions with warm water and antibacterial soap three times a day
to soften and remove crusts.

B. Apply antibiotic ointment, i.e. triple antibiotic ointment, tid for 7-10 days or until all lesions
have cleared following the cleansing procedure. Re-evaluate if no response in 3-5 days.

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