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 Impetigo is a common and highly contagious bacterial skin infection, particularly prevalent among infants and young children, though it can affect individuals of any age. Characterized by red sores that quickly rupture, ooze, and form a honey-colored crust, impetigo is often a source of discomfort and concern for affected individuals and their caregivers. While generally not serious, prompt diagnosis and appropriate treatment are essential to prevent its spread, alleviate symptoms, and avoid potential complications. Understanding the causative agents, clinical presentations, and therapeutic approaches for impetigo is key to effective management.

What is Impetigo?

Impetigo is a superficial skin infection, meaning it affects the outermost layers of the epidermis. It is primarily caused by two types of bacteria:

• Staphylococcus aureus (Staph): The most common cause, responsible for both non-bullous and bullous forms.

• Streptococcus pyogenes (Group A Strep): Less common but can also cause non-bullous impetigo. In some cases, both bacteria may be present.

The bacteria typically enter the skin through minor cuts, scrapes, insect bites, or existing skin conditions (like eczema, scabies, or chickenpox) that compromise the skin barrier. It thrives in warm, humid environments and spreads easily through direct skin-to-skin contact or by sharing contaminated items like towels, clothing, or toys.

Types and Symptoms of Impetigo

There are two main types of impetigo, each with distinct characteristics:

1. Non-bullous Impetigo (Crusted Impetigo):

   • Prevalence: This is the most common form, accounting for about 70% of cases.

   • Appearance: Begins as small, red sores, often around the nose and mouth, but can appear anywhere on the body. These sores quickly break open, ooze fluid or pus, and then form a characteristic honey-colored crust.

   • Symptoms: Lesions are typically itchy but usually not painful. They can enlarge and spread, forming new patches. Swollen lymph nodes near the affected area are common.

2. Bullous Impetigo:

   • Prevalence: Less common, primarily affecting infants and young children.

   • Appearance: Characterized by larger, fluid-filled blisters (bullae) that appear clear initially, then become cloudy. These blisters typically rupture, leaving a raw-looking, moist area that then crusts over with a yellowish-brown crust (less honey-colored than non-bullous).

   • Symptoms: Bullae may be itchy but usually not painful. The surrounding skin is often red and itchy. Systemic symptoms like fever or malaise are rare but can occur. Bullous impetigo is exclusively caused by Staphylococcus aureus strains that produce a toxin (exfoliatin) that causes skin separation.

Ecthyma: A more severe form of impetigo that penetrates deeper into the skin layers. It causes painful, pus-filled sores that develop into deeper ulcers with a hardened crust. Ecthyma requires more aggressive treatment and can lead to scarring.

Diagnosis

Diagnosis of impetigo is typically made clinically by a healthcare professional based on the characteristic appearance of the sores and crusts. In most cases, laboratory tests are not necessary. However, if the infection is widespread, severe, not responding to treatment, or if there is concern for MRSA (methicillin-resistant Staphylococcus aureus), a bacterial culture of the fluid from the sores may be performed to identify the specific bacteria and determine its antibiotic susceptibility.

Treatment Approaches

Prompt treatment of impetigo is important to prevent complications, reduce the risk of transmission to others, and alleviate discomfort.

1. Topical Antibiotics:

   • First-line for localized, mild cases.

   • Medications: Mupirocin ointment (Bactroban) or retapamulin ointment. These are applied directly to the lesions several times a day for about 5-7 days.

   • Application: Before applying, gently wash the affected areas with soap and water to remove crusts, which helps the antibiotic penetrate.

2. Oral Antibiotics:

   • Indicated for widespread or more severe cases, bullous impetigo, ecthyma, or if topical treatment is ineffective.

   • Medications: Common choices include penicillinase-resistant penicillins (e.g., dicloxacillin, flucloxacillin), cephalosporins (e.g., cephalexin), or clindamycin. For suspected or confirmed MRSA, other antibiotics like trimethoprim-sulfamethoxazole or doxycycline may be used (doxycycline is typically avoided in young children due to potential tooth discoloration).

   • Duration: Typically taken for 7-10 days.

General Care and Prevention

Alongside antibiotic treatment, several measures can help manage impetigo and prevent its spread:

• Hygiene: Keep the affected skin clean by gently washing with soap and water.

• Covering Lesions: Cover the sores with gauze and tape or loose-fitting clothing to prevent scratching and spread.

• Handwashing: Frequent and thorough handwashing with soap and water is crucial for both the infected individual and caregivers.

• Avoid Scratching: Trim fingernails short to reduce skin damage and spread of bacteria.

• Isolate Personal Items: Do not share towels, washcloths, bedding, clothing, or razors.

• Exclusion from School/Daycare: Children with impetigo should typically stay home from school or daycare until the lesions are no longer weeping and crusting, or for 24 hours after starting antibiotic treatment.

• Treating Underlying Conditions: Address any underlying skin conditions (e.g., eczema) that might make the skin more vulnerable to infection.

Potential Complications

While impetigo is usually benign, untreated or severe cases can lead to complications:

• Cellulitis: A deeper, more serious skin infection that can spread to the bloodstream.

• Post-streptococcal Glomerulonephritis (PSGN): A rare kidney disease that can occur after infection with certain strains of Streptococcus pyogenes (nephritogenic strains). This complication is more common with non-bullous impetigo caused by Group A Strep and is not prevented by antibiotic treatment of the impetigo itself.

• Scarring: More likely with ecthyma than typical impetigo.

Impetigo is a manageable bacterial infection when identified and treated promptly. Public health efforts focused on hygiene education and early intervention are key to controlling its spread and minimizing its impact, especially in vulnerable populations.

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