Impetigo, antibiotic use and hydrogen peroxide 1% cream

Image by James Heilman, MD

This is a new guideline from NICE on the use of antibiotics in impetigo. It was published in Feb 20.

My key learning point from this is that we should now consider using hydrogen peroxide 1% cream as the first line in localised non-bullous impetigo.

Why the change in practice?

Impetigo can get better by itself. However we normally want to treat it because it is infectious and causes people to have time out of education or work.

Research (based on an RCT) shows that hydrogen peroxide 1% cream is as effective as topical antibiotics at curing localised non-bullous impetigo. At this strength, the risk of side-effects is low. It doesn't increase antibiotic resistance like antibiotics will.

There are other cheaper and readily available antiseptics, however NICE couldn't find any research on their use and so hasn't been able to make a recommendation on them.

What are the practicalities of using hydrogen peroxide 1% cream?

You can't use it around the eyes.

It can cause skin irritation and bleaching, but this is unlikely at this concentration.

There is only 1 formulation at present and this is Crystacide 1% cream. It's quite a lot more expensive than fusidic acid.

It is licensed in children and no lower age is specified.

You use it 2 - 3 times a day. NICE advises using it for 5 days.

If the impetigo doesn't clear up with the hydrogen peroxide 1% cream, then use a topical antibiotic, or an oral one, depending on how widespread it is and it's nature (see below).

What other treatments for impetigo are advised?

I am not summarising all the management as not much else has changed. There is an excellent visual summary from NICE.

Topical or oral? They are leaving this to our clinical judgement, though they do advise oral antibiotics for bullous impetigo. Interestingly, I hadn't realised that there is a higher risk of resistance with topical antibiotics than with oral antibiotics. However NICE felt that this was offset by the higher risk of side-effects with oral antibiotics.

Mupirocin 2% is advised as the second line topical treatment.

How long should treatment last?

NICE advises that topical and oral antibiotics be used for just a 5 day course, rather than the traditional 7. This is not based upon evidence, but upon the committee's experience and what they felt current practice was. They do advise that a 7 day course can be used based upon how widespread the infection is and how many lesions there are.

Fucidic acid cream and mupirocin can not be used for more than 10 days.

What about recurrent impetigo?

Send a skin swab and also consider taking a nasal swab and starting treatment for decolonisation. Family decolonisation may be needed, but NICE advise they haven't made a recommendation on this as it would be upon specialist advice.

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