Impetigo Management in the Retail Clinic

Marjorie R. Rachide, MSN, FNP-BC, APRN
Tuesday August 30, 2016
Impetigo is a bacterial infection presenting with superficial skin involvement most commonly on the face, although it may also present on other sites, such as arms and legs. Most common in young children 2 to 6 years old, the contagious nature of impetigo poses a concern in day care to other children and caregivers. Causative bacteria are Staphylococcus (at 80% frequency) followed by group A Streptococcus (in 20% to 30% of cases).

Presentation involves circular lesions, a red base, and sometimes pustules on a red base. Lesions initially fill with clear fluid, and then purulent material ruptures in a few days. Thick, honey-colored crusts soon develop over a few days. The bullous form of impetigo will have individual lesions enlarging often to 2 cm or more, which coalesce with minimal surrounding erythema. The bullae may collapse, leaving central surface erosion of various sizes with scales at the periphery. The honey-colored crust then develops.

The lesions are mildly itchy, and scratching often spreads them to other places or individuals by contact with the lesions themselves or nasal drainage. Treatment is with antibiotics—topical for most presentations and oral for more severe presentations. If colonization of the nasal passages is suspect or identified, eradication is undertaken. This disease is self-limiting, and if left untreated, it may spread and last for weeks. Rarely are systemic complications encountered. Lymphadenopathy and fever may occur with widespread areas of infection. Exclusion of methicillin-resistant Staphylococcus aureus (MRSA) is a consideration, particularly with poor response or resistance to initial therapy.

Impetigo Case Study
Sam, a 4-year-old child, presents to the clinic with his mother with a 3-day history of yellow sticky and crusty discharge on the left side of his nose and around the left side of his mouth. One week prior, Sam broke out in cold sores in the same area. Other than periodic cold sores, his medical history is unremarkable and medication allergies are denied. There is no fever, chills, or systemic symptoms, and the area of note is enlarging. Sam is not experiencing changes in affect, energy level, or gastrointestinal symptomology. He does attend day care.

DISCUSSION QUESTION: 
What additional information would you want to know about Sam’s history and current illness? Is there diagnostic testing to consider?

ANSWER:
Additional information to aid the diagnostic process includes any previous episodes or exposures of similar rashes and any treatments tried at home or remedies used in any previous episodes. Are there any other family members or play-group friends with similar crusty lesions?

Sam’s physical examination shows an afebrile healthy child with no lymphadenopathy. The nares show mild erythema. Isolated to the left side of the perioral region are multiple vesicles with a red moist base, a honey-colored crust, and mild scaling at the borders. Little surrounding erythema is noted, and few satellite lesions are present.

Clinical diagnosis may be made without additional testing. Because the lesions are predominately caused by Staphylococcus bacteria, consideration of MRSA may be given in lesions that Impetigo fail to respond to initial therapy or if abscesses or cellulitis develop. A culture then would be helpful. Hematology is usually not helpful as it is not affected.


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