The skin is normally populated with bacteria, and under healthy normal circumstances these bacteria do not routinely lead to infection. When there is an interruption to skin integrity or underlying immunocompromise however, these bacteria can cause an infection such as impetigo (VanRavenstein, Durham, Williams, & Smith, 2017). Ferri (2018) defines impetigo as a common bacterial superficial skin infection that is generally caused by streptococcal or staphylococcal bacteria. Skin lesions can be described a bullous when multiple vesicles form on the skin, enlarge, and weep a yellow honey-like crust due to a toxin produced at the site of the infection (Ferri, 2018). As the weeping lesions become contagious and spread to the others, a dry scaly boarder forms to replace the old fluid-filled vesicle (Ferri, 2018). Non-bullous impetigo begins as a single red papule, usually around the nose or mouth, weep and produce a honey-like crust (Ferri, 2018).
Bullous impetigo is most commonly caused by staphylococcal bacteria and accounts for thirty-percent of cases, whereas non-bullous impetigo is most commonly caused by streptococcal bacteria and remains the leading cause of impetigo, or around seventy-percent of the cases (Ferri, 2018). Impetigo is the most usual form of skin infections for pediatric populations in the age group of two to five (Ferri, 2018). Impetigo most often occurs in warm and humid climates, and can often accompany and complicate other interruptions of the skin such as poison ivy, insect bites, or eczema (Ferri, 2018).
Physical assessment and examination will include a history of presenting illness as well as an overall skin assessment. The hallmark sign of impetigo is the weeping honey-like crust and scaly dry skin around the lesions, and for this reason, diagnostic lab testing is usually not necessary. If there is concern for underlying illness or if clinical presentation is not clear, a gram stain and culture of the site can be done (Ferri, 2018).
The evidence-based treatment plan and education should begin with self-skin care by encouraging removal of the crust with a warm cloth, as creams used for treatment can not penetrate through the crusty layer (Ferri, 2018). The patient should apply 2% mupirocin (Bactroban) ointment, three times per day, for ten days. Education should also include hygiene topics such as keeping nails trimmed short to prevent accidentally scratches or injury to the skin (Ferri, 2018). Hartman-Adams, Banvard, and Juckett (2014) state that with children, practices such as cleaning skin injuries with soap and water, regular hand hygiene, and daily bathing can help prevent infection when children are in frequent contact with other children such as daycare settings. Purposeful and frequent changing of towels and linens that touch the infected areas should be implemented, as well as education to not share these linens with anyone else due to impetigo being highly contagious. Children who attend daycare or other public groups should be kept home for seventy-two hours after initiating antibiotic ointment treatment (Ferri, 2018).
Skin lesions should resolve promptly with appropriate use of the antibiotic ointment, so the patient should return to the clinic at the end of the ten-day treatment if skin lesions and symptoms have not resolved, or sooner if the symptoms worsen. If the patient is having recurrent impetigo, a culture of the nares can also be completed to rule out this being a carrier site of infection, and oral antibiotics many need to be initiated for severe cases (Ferri, 2018).
Reference:
Ferri, F. F. (2018). 2018 Ferri’s clinical advisor. Philadelphia, PA: Elsevier.
Hartman-Adams, H., Banvard, C., & Juckett, G. (2014). Impetigo: Diagnosis and treatment. American Family Physician, 90(4), 229-235.
VanRavenstein, K., Durham, C.O., Williams, T., & Smith, W. (2017). Diagnosis and management of impetigo. The Nurse Practitioner, 42(3), 40-44. doi:10.1097/01.NPR.0000508173.18540.51
