The effect of antibacterial soap on impetigo incidence, Karachi, Pakistan. Short-course oral co-trimoxazole versus intramuscular benzathine benzylpenicillin for impetigo in a highly endemic region: an open-label, randomised, controlled, non-inferiority trial Comparison of mupirocin and erythromycin in the treatment of impetigo. The microbiology of impetigo in Indigenous children: associations between Streptococcus pyogenes, Staphylococcus aureus,scabies, and nasal carriage Impetigo. Current etiology and comparison of penicillin, erythromycin, and cephalexin therapies. Mass Drug Administration for Scabies Control in a Population with Endemic Disease. The antibacterial activity of tea in vitro and in vivo (in patients with impetigo contagiosa). Treatment of impetigo and ecthyma. A comparison of sulconazole with miconazole. Topical antibiotics in the treatment of superficial skin infections in general practice--a comparison of mupirocin with sodium fusidate. Topical antibiotic treatment of impetigo with mupirocin. Effect of Antenatal Zinc Supplementation on Impetigo in Infants in Bangladesh
We conducted a study to determine if soap containing 1.2 % triclocarban would be effective in reducing the incidence of impetigo . We r and omized 162 households in a low-income neighborhood of Karachi , Pakistan , to receive a regular supply of 1.2 % triclocarban-containing soap ( n = 81 ) or an identically appearing placebo ( n = 81 ) ; 79 households in a nearby neighborhood were enrolled as st and ard practice controls . After adjustment for household clustering and covariates , the incidence of impetigo among children living in households receiving triclocarban-containing soap ( 1.10 episodes per 100 person-weeks ) was 23 % lower than in households receiving placebo soap ( P = 0.28 ) and 43 % lower than the st and ard habit and practice controls ( P = 0.02 ) . The routine use of triclocarban-containing soap by children living in a community with a high incidence of impetigo was associated with a reduced incidence of impetigo BACKGROUND Impetigo affects more than 110 million children worldwide at any one time . The major burden of disease is in developing and tropical setting s where topical antibiotics are impractical and lead to rapid emergence of antimicrobial resistance . Few trials of systemic antibiotics are available to guide management of extensive impetigo . As such , we aim ed to compare short-course oral co-trimoxazole with st and ard treatment with intramuscular benzathine benzylpenicillin in children with impetigo in a highly endemic setting . METHODS In this r and omised , controlled , non-inferiority trial , Indigenous Australian children aged 3 months to 13 years with purulent or crusted non-bullous impetigo were r and omly assigned ( 1:1:1 ) to receive benzathine benzylpenicillin ( weight-b and ed injection ) , twice-daily co-trimoxazole for 3 days ( 4 mg/kg plus 20 mg/kg per dose ) , or once-daily co-trimoxazole for 5 days ( 8 mg/kg plus 40 mg/kg per dose ) . At every visit , participants were r and omised in blocks of six and 12 , stratified by disease severity . R and omisation was done by research nurses and codes were in sealed , sequentially numbered , opaque envelopes . Independent review ers masked to treatment allocation compared digital images of sores from days 0 and 7 . The primary outcome was treatment success at day 7 in a modified intention-to-treat analysis . This trial is registered with the Australian New Zeal and Clinical Trials Registry , number ACTRN12609000858291 . FINDINGS Between Nov 26 , 2009 , and Nov 20 , 2012 , 508 patients were r and omly assigned to receive benzathine benzylpenicillin ( n=165 [ 156 analysed ] ) , twice-daily co-trimoxazole for 3 days ( n=175 [ 173 analysed ] ) , or once-daily co-trimoxazole for 5 days ( n=168 [ 161 analysed ] ) . Treatment was successful in 133 ( 85 % ) children who received benzathine benzylpenicillin and 283 ( 85 % ) who received pooled co-trimoxazole ( absolute difference 0·5 % ; 95 % CI -6·2 to 7·3 ) , showing non-inferiority of co-trimoxazole ( 10 % margin ) . Results for twice-daily co-trimoxazole for 3 days and once-daily co-trimoxazole for 5 days were similar . Adverse events occurred in 54 participants , 49 ( 90 % ) of whom received benzathine benzylpenicillin . INTERPRETATION Short-course co-trimoxazole is a non-inferior , alternative treatment to benzathine benzylpenicillin for impetigo ; it is palatable , pain-free , practical , and easily administered . FUNDING Australian National Health and Medical Research Council For the past two decades the accepted treatment of impetigo has been systemic antibiotic therapy , l The recently approved topical antibiotic mupirocin has excellent in vitro activity against Streptococcus pyogenes and Staphylococcus aureus , including multiply resistant strains . Originally called pseudomonic acid A , mupirocin is obtained from submerged fermentation of Pseudomonas fluorescens ; it acts by inhibition of bacterial protein synthesis by inactivation of isoleucyl transfer RNA synthetase . Rapidly inactivated and rapidly excreted when given systemically , mupirocin has been shown to be safe in animal and human trials.2 , 3 Double-blind studies prove mupirocin to be more effective than its polyethylene glycol vehicle for treatment of impetigo.4 , 5 Several nonblind or poorly controlled clinical trials have suggested that mupirocin  's  efficacy is comparable to that of orally administered antibiotics commonly used to treat impetigo , namely , erythromycin , 6 - 1~ ampicillin , 11 and dicloxacillin . 12 We intended to vali date these findings in a double-blind , placebo-controlled study . We further hypothesized that erythromycin would cause more adverse side effects and result in poorer compliance , making mupirocin the preferred medication Background Impetigo is caused by both Streptococcus pyogenes and Staphylococcus aureus ; the relative contributions of each have been reported to fluctuate with time and region . While S. aureus is reportedly on the increase in most industrialised setting s , S. pyogenes is still thought to drive impetigo in endemic , tropical regions . However , few studies have utilised high quality microbiological culture methods to confirm this assumption . We report the prevalence and antimicrobial resistance of impetigo pathogens recovered in a r and omised , controlled trial of impetigo treatment conducted in remote Indigenous communities of northern Australia . Methods Each child had one or two sores , and the anterior nares , swabbed . All swabs were transported in skim milk tryptone glucose glycogen broth and frozen at –70 ° C , until plated on horse blood agar . S. aureus and S. pyogenes were confirmed with latex agglutination . Results From 508 children , we collected 872 swabs of sores and 504 swabs from the anterior nares prior to commencement of antibiotic therapy . S. pyogenes and S. aureus were identified together in 503/872 ( 58 % ) of sores ; with an additional 207/872 ( 24 % ) sores having S. pyogenes and 81/872 ( 9 % ) S. aureus , in isolation . Skin sore swabs taken during episodes with a concurrent diagnosis of scabies were more likely to culture S. pyogenes ( OR 2.2 , 95 % CI 1.1 – 4.4 , p = 0.03 ) . Eighteen percent of children  had nasal carriage of skin pathogens . There was no association between the presence of S. aureus in the nose and skin . Methicillin-resistance was detected in 15 % of children who cultured S. aureus from either a sore or their nose . There was no association found between the severity of impetigo and the detection of a skin pathogen . Conclusions S. pyogenes remains the principal pathogen in tropical impetigo ; the relatively high contribution of S. aureus as a co-pathogen has also been confirmed . Children with scabies were more likely to have S. pyogenes detected . While clearance of S. pyogenes is the key determinant of treatment efficacy , co-infection with S. aureus warrants consideration of treatment options that are effective against both pathogens where impetigo is severe and prevalent . Trial registration This trial is registered ; ACTRN12609000858291 We attempted to determine the causative bacterial pathogens of impetigo in children in our area , to compare the effectiveness of three frequently used oral antimicrobial treatment regimens , and to correlate the antimicrobial sensitivity of the bacterial isolates with clinical responses to treatment . Seventy-three children with impetigo were r and omly assigned to receive penicillin V potassium or cephalexin monohydrate , both administered in dosages of 40 to 50 mg/kg per day , or erythromycin estolate administered in a dosage of 30 to 40 mg/kg per day . All drugs were given in three divided doses for 10 days . Treatment failure was defined as persistence of lesions 8 to 10 days after initiation of drug therapy as determined by examiners blinded to the treatment therapies . Forty-five ( 62 % ) cultures showed Staphylococcus aureus only , 14 ( 19 % ) showed S aureus and group A beta-hemolytic streptococci , six ( 8 % ) showed group A beta-hemolytic streptococci only , and eight ( 11 % ) showed no growth or other organisms . Treatment failure occurred in six ( 24 % ) of 25 patients treated with penicillin V , one ( 4 % ) of 25 patients treated with erythromycin estolate , and no patients treated with cephalexin . We conclude that S aureus is the most common cause of impetigo in children in our study population , that cephalexin is the most effective treatment , that erythromycin estolate is nearly equally effective and may be preferred on a cost-effectiveness basis , and that penicillin V is inadequate for treatment of this infection BACKGROUND Scabies is an underrecognized cause of illness in many developing countries . It is associated with impetigo , which can lead to serious systemic complications . We conducted a trial of mass drug administration for scabies control in Fiji . METHODS We r and omly assigned three isl and communities to one of three different interventions for scabies control : st and ard care involving the administration of permethrin to affected persons and their contacts ( st and ard-care group ) , mass administration of permethrin ( permethrin group ) , or mass administration of ivermectin ( ivermectin group ) . The primary outcome was the change in the prevalence of scabies and of impetigo from baseline to 12 months . RESULTS A total of 2051 participants were enrolled ; 803 were in the st and ard-care group , 532 in the permethrin group , and 716 in the ivermectin group . From baseline to 12 months , the prevalence of scabies declined significantly in all groups , with the greatest reduction seen in the ivermectin group . The prevalence declined from 36.6 % to 18.8 % in the st and ard-care group ( relative reduction in prevalence , 49 % ; 95 % confidence interval [ CI ] , 37 to 60 ) , from 41.7 % to 15.8 % in the permethrin group ( relative reduction , 62 % ; 95 % CI , 49 to 75 ) , and from 32.1 % to 1.9 % in the ivermectin group ( relative reduction , 94 % ; 95 % CI , 83 to 100 ) . The prevalence of impetigo also declined in all groups , with the greatest reduction seen in the ivermectin group . The prevalence declined from 21.4 % to 14.6 % in the st and ard-care group ( relative reduction , 32 % ; 95 % CI , 14 to 50 ) , from 24.6 % to 11.4 % in the permethrin group ( relative reduction , 54 % ; 95 % CI , 35 to 73 ) , and from 24.6 % to 8.0 % in the ivermectin group ( relative reduction , 67 % ; 95 % CI , 52 to 83 ) . Adverse events were mild and were reported more frequently in the ivermectin group than in the permethrin group ( 15.6 % vs. 6.8 % ) . CONCLUSIONS Mass drug administration , particularly the administration of ivermectin , was efficacious for the control of scabies and impetigo . ( Funded by the Australian National Health and Medical Research Council ; Australian New Zeal and Clinical Trials Registry number , ACTRN12613000474752 . ) A total number of 104 patients with impetigo contagiosa was included in this study . They were 47 females ( 45.2 % ) and 57 males ( 54.8 % ) . Their ages ranged from one month to 40 years with a median of 4 years . This study was divided into two parts : PART I ( in vitro ) : Thirty-five patients were swabbed to determine the microbiology of impetigo contagiosa which included 33 isolates of pure S. aureus ( 94.3 % ) and 2 of a combination of S. aureus and Streptococcus pyogenes ( 5.7 % ) . The antibacterial effect of tea liquor ( lotion ) against S. aureus proved very effective . Antibiotic sensitivity was done for all bacterial isolates of S. aureus . PART II ( in vivo ) : The antibacterial effects of tea liquor and ointment were tested by treating 64 patients with impetigo contagiosa . Tea ointment was very effective with a cure rate of 81.3 % . Forty patients were taken as controls and divided into two groups . The first one was given an ointment containing Framycetin and gramicidin ( soframycin ) with a cure rate of 72.2 % ; the other group was given oral cephalexin with a cure rate of 78.6 % . To the best of our knowledge , this study was the first one which demonstrated the anti-bacterial action of crude tea in vivo , against impetigo contagiosa . Clinical data about impetigo are also included in this study In a r and omized , double-blind , parallel comparative study of 80 patients , impetigo and ecthyma were treated effectively by sulconazole nitrate 1 % cream and miconazole nitrate 2 % cream applied to lesions twice daily for 14 days . When treatment began , bacterial cultures from all pyodermal lesions yielded Group A beta-hemolytic streptococci or pathogenic staphylococci . Among the 32 sulconazole-treated impetigo patients , bacterial cultures from 26 ( 69 % ) were negative by treatment day 4 , and those from all 32 ( 100 % ) were negative by treatment day 7 ; among the 34 miconazole-treated impetigo patients , cultures from 17 ( 50 % ) were negative by treatment day 4 , cultures from 32 ( 94.1 % ) were negative by treatment day 7 , and cultures from 29 ( 97 % ) were negative by treatment day 14 . Each treatment promptly relieved the pyodermal signs ( crusts , vesicles , pustules , bullae , and exu date ) . Both agents were considered to be safe and effective medications for treating impetigo and ecthyma A total of 413 eligible patients took part in an observer-blind r and omised multicentre clinical trial in order to compare the clinical and bacteriological efficacy of mupirocin ( Bactroban ) ointment with sodium fusi date ( Fucidin ) ointment for treating  superficial skin infections seen in general practice .  Mupirocin was applied twice daily and sodium fusi date thrice daily for a period of 7 days . Both treatments were similarly effective with 97 % patients treated with mupirocin and 93 % patients treated with sodium fusi date responding . Mupirocin was significantly more effective in the treatment of acute primary skin infections and in the treatment of a subgroup of patients with impetigo ( P less than 0.01 ) . Of the organisms detected before treatment began , 93 % were not found after treatment with mupirocin compared with 89 % after treatment with sodium fusi date .  Staphylococcus aureus and /or beta-haemolytic streptococci appeared to be eliminated in significantly more patients treated with mupirocin ( 96 % ) compared with those treated with sodium fusi date ( 88 % ) , ( P = 0.03 ) . Both treatments were well tolerated Because the effectiveness of topical antimicrobials in the treatment of ecthyma , impetigo , and pyoderma is not well established , the US Food and Drug Administration has recently proposed guidelines for tests of topical antimicrobial efficacy in primary skin infections . The guidelines require both comparison with the agent 's base and microbiologic documentation of efficacy . These guidelines were followed in this double-blind , eight-day evaluation of impetigo/ecthyma treated with mupirocin , a new agent that is only active topically . All cultures , before and after therapy , were taken using swabs dipped in neutralizing broth plus 10 % fetal bovine serum to minimize antimicrobial " carry over " to the culture plate . Staphylococcus aureus , which was isolated from 94 % of the patients before therapy , was eliminated in 88 % of the mupirocin-treated patients and 47 % of the vehicle-treated patients . Group A beta-hemolytic streptococci were eliminated in 100 % of the mupirocin-treated and 0 % of the vehicle-treated patients . To our knowledge , this is the first topical antibacterial treatment for  primary skin infections proved superior to its vehicle using the proposed US Food and Drug Administration guidelines We sought to determine the effects of maternal zinc supplementation on  skin infections among infants in poor urban areas of Dhaka , Bangladesh . A double-blind , placebo-controlled , r and omized trial was conducted among 199 and 221 Bangladeshi infants whose mothers were administered 30 mg daily of zinc or placebo , respectively . The mothers received zinc supplementation from 12–16 weeks ’ gestation until delivery , and the infants were followed up until 6 months of age . Among the infants of mothers who received zinc supplementation during the antenatal period , 10.6 % had at least 1 episode of impetigo compared with 19.6 % of the infants of mothers in the placebo group ( P = 0.01 ) . Infants in the treatment group had a 54 % reduction in incidence rate of episodes of impetigo when compared with infants in the placebo group ( P = 0.01 ) . The effect of zinc supplementation was more pronounced among male infants ( 64 % reduction ) and intrauterine growth restricted and low birth weight infants ( 73 % reduction ) and among infants of mothers with increased parity ( 60 % reduction ) or decreased socioeconomic status ( 71 % reduction )
This review found limited high- quality evidence to inform the treatment of impetigo .
BACKGROUND Impetigo is a common clinical problem seen in general practice .
Uncertainty exists as to the most effective treatment , or indeed if treatment is necessary .
AIM To determine the most effective treatment for impetigo in a systemically well patient .