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Visual Diagnosis

Case: A 4-year-old girl presents with a crusted facial rash centered around her nose and mouth and some scattered lesions on her extremities.

Herpetic whitlow in a 7-year-old boy

Diagnosis:

This patient has nonbullous impetigo.

Nonbullous impetigo initially presents as erythematous papules that evolve into vesicles and pustules, leaving behind crusted honey-colored lesions on an erythematous base after rupturing.1 Sites of infection are commonly areas that have sustained minor trauma, compromising skin integrity.

Clinical Practice Pearls:

  • Impetigo can occur at any age. The presentation can be bullous, which is most common in neonates and infants, or nonbullous, which comprises the majority of all cases.
  • Staphylococcus aureus and group A Streptococcus (GAS) cause nonbullous impetigo, while certain strains of S aureus that produce a toxin causing cleaving at the dermal-epidermal junction is implicated in bullous impetigo.
  • The infection can be self-limited, resolving in 2 to 3 weeks without treatment. Treatment, which can be topical or oral for both bullous and nonbullous impetigo, is associated with higher cure rates, with resolution of lesions over 7 to 10 days.
    • The use of a topical ointment, such as mupirocin or retapamulin, is the treatment of choice.1-3
    • Oral medications, such as beta-lactamase-resistant antibiotics, or antibiotics effective against a suspected methicillin-resistant S aureus infection, should be prescribed in patients with numerous lesions or patients who are immunocompromised.
    • Medications for relief of pruritus may also be indicated.
  • It is recommended that children should stay home from school until 24 hours after initiation of therapy.

Further Reading:

  • Hirschmann JV. Impetigo: etiology and therapy. Curr Clini Top Infect Dis. 2002;22:42-51.
  • Koning S, van der Sande R, Verhagen AP, et al. Interventions for impetigo. Cochrane Database Syst Rev. 2012;1:CD003261.
  • Johnston GA. Treatment of bullous impetigo and the staphylococcal scalded skin syndrome in infants. Expert rev Anti Infect Ther.2004;2(3):439-446.
  • Sanders JE, Garcia SE. Evidence- based management of skin and soft tissue infections in pediatric patients in the emergency department. Pediatr Emerg Med Pract. 2015;12(2):1-24.

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