On this page
Referral and warning signs
When to refer
Refer if: Extensive lesions, Signs of systemic illness (fever, malaise), No improvement after 5-7 days of appropriate treatment, Recurrent episodes, Complications develop (cellulitis, PSGN suspected).
Red flags
- High fever.
- Rapidly spreading redness/swelling (cellulitis).
- Signs of SSSS (widespread blistering/peeling).
- Signs of PSGN (oedema, hypertension, haematuria).
Signs and symptoms
- Common in children.
- Lesions usually on face, head, and hands.
- Non-bullous: Small vesicles or pustules rupture to form characteristic honey-coloured crusts on an erythematous base.
- Bullous: Flaccid blisters (bullae) containing pus/serum, often in axilla and groin.
Risk factors
- Poor hygiene.
- Minor skin trauma (cuts, insect bites).
- Crowded living conditions.
- Warm, humid climates.
- Pre-existing skin conditions (e.g., eczema, scabies).
Diagnosis
Clinical assessment
Diagnosis is primarily clinical, based on the characteristic appearance of lesions (honey-coloured crusts or flaccid bullae).
Differential diagnosis
- Herpes simplex.
- Varicella (Chickenpox).
- Scabies (crusted/infected).
- Contact dermatitis.
- Fungal infections (Tinea).
- Pemphigus foliaceus (rare autoimmune blistering).
Investigations
- Usually not required for diagnosis.
- Pus swab for Gram stain, Culture & Sensitivity (from unroofed lesion or blister fluid) - if severe, recurrent, or unresponsive to treatment.
Diagnostic criteria
Clinical appearance of characteristic lesions.
Management
Non-pharmacological management
- Clean affected area with antiseptic solution (e.g., Chlorhexidine 0.05%) or soap and water. (LOC: HC2)
- Gently remove superficial crusts after softening with soap and water to allow topical treatment penetration. (LOC: HC2)
- Keep skin clean by frequent washing and drying. (LOC: HC2)
- Advise good hygiene (hand washing, keep fingernails short) to prevent spread.
- Isolate/separate from others if admitted (contagious).
Pharmacological treatment
- Mild, Localized Infection (<5 lesions):
- - Topical Antiseptic: Gentian Violet 0.5% aqueous paint BID for 3 days. (LOC: HC2)
- - OR Topical Antibiotic: Mupirocin 2% ointment TID for 5-7 days OR Fusidic acid cream/ointment (if available).
- - OR Silver Sulphadiazine 1% cream BID for 5 days (UCG option).
- More Extensive Infection (>5 lesions or signs of spread):
- - Systemic Antibiotics (Cover Staph/Strep):
- - Cloxacillin 250–500 mg PO QID (before food) for 7 days. (Child: 12.5–25 mg/kg/dose). (LOC: HC2)
- - OR Amoxicillin/Clavulanate.
- - Alternative (Penicillin Allergy): Erythromycin 250-500 mg PO QID for 7 days. (Child: 7.5-12.5 mg/kg/dose - dose adjust based on severity/age). (LOC: HC2)
Monitoring
Assess for improvement within a few days. Lesions should dry up and heal. Monitor for spread or systemic signs.
Complications
- Cellulitis.
- Lymphangitis.
- Post-streptococcal glomerulonephritis (PSGN) - rare, associated with certain Strep strains.
- Staphylococcal Scalded Skin Syndrome (SSSS) - rare, with bullous impetigo.
- Scarring (usually minimal).
Prevention
- Good personal hygiene (regular bathing/showering with soap).
- Prompt cleaning and care of minor skin injuries.
- Hand washing.
- Avoiding sharing towels/personal items with infected individuals.
Patient education
- Explanation of impetigo as a contagious skin infection.
- Importance of hygiene (washing, not scratching).
- How to apply topical treatments or take oral antibiotics.
- Need to complete the full course of antibiotics.
- Preventing spread to others (avoid sharing towels, keep lesions covered if possible).
Uganda-specific notes
Very common, especially in children. Often co-infection with Staph and Strep. Gentian Violet widely used for mild cases. Cloxacillin is standard oral choice. Consider underlying scabies or poor hygiene.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 22, Section 22.1.1