Synopsis
Distinguish superficial impetigo from deeper ulcerative ecthyma and important blistering mimics, use hygiene and finite antimicrobial treatment proportionately, and investigate non-response or recurrence.
- Non-bullous impetigo begins with thin-roofed vesicles or pustules that become honey-coloured crusted erosions, commonly around the nose, mouth and exposed limbs.
- Bullous impetigo produces larger flaccid blisters, often on trunk or flexures, and warrants oral treatment because toxin-producing staphylococci are involved.
- Ecthyma has an adherent dark crust over a punched-out ulcer extending into dermis; swab and use systemic treatment rather than treating it as a superficial spot.
Key red flags
Systemic toxicity, rapidly spreading pain or erythema, extensive bullae, mucosal involvement, periorbital disease, immunocompromise, neonatal infection, dehydration or suspected staphylococcal scalded-skin syndrome requires urgent assessment.
Rapidly expanding warmth, swelling and pain beyond lesions, fever or physiological instability indicates cellulitis or sepsis and needs urgent care.
Investigation priorities
Classify non-bullous, bullous, ecthyma or invasive disease and choose treatment route.
Management branches
A small area of superficial honey-crusted lesions occurs without bullae, systemic illness or high complication risk.
- Offer hydrogen peroxide 1% cream two or three times daily for five days and explain local irritation and eye avoidance.
- If unsuitable or ineffective, choose a five-day topical antibiotic according to NICE and local resistance, rather than combining products.