Impetigo contagiosa: suppurative and non-suppurative complications. I. Clinical, bacteriologic, and epidemiologic characteristics of impetigo.
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Adolescent↗
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[Staphylogenous impetigo and impetigo infected artifacts, lupus erythematosus chronicus, Boeck's sarcoidosis, lupus miliaris faciei, eczema herpeticatum, eosinophilic granuloma, acanthosis, nigricans, subungual melanoma].
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Acanthosis Nigricans↗
Impetigo: an overview.
This article reviews in detail the pathogenesis, clinical characteristics and management of impetigo in children. Impetigo is the most common bacterial skin infection of children. Most cases of nonbullous impetigo and all cases of bullous impetigo are caused by Staphylococcus aureus. The remainder of cases of nonbullous impetigo are due to group A beta hemolytic streptococci (GABHS). GABHS colonize the skin directly by binding to sites on fibronectin that are exposed by trauma. In contrast, S. aureus colonizes the nasal epithelium first; from this reservoir, colonization of the skin occurs. Patients with recurrent impetigo should be evaluated for carriage of S. aureus. Superficial, localized impetigo may be treated successfully in more than 90% of cases with topical application of mupirocin ointment. Impetigo that is widespread or involves deeper tissues should be treated with a beta-lactamase-resistant oral antibiotic. The choice of antibiotics is affected by the local prevalence of resistance to erythromycin among strains of S. aureus, antibiotic cost and availability, and issues of compliance.
Anti-Bacterial Agents↗
Bullous impetigo in homosexual men--a risk marker for HIV-1 infection?
OBJECTIVE: To determine the incidence of bullous impetigo in a group of homosexual men at high risk of HIV-1 infection. DESIGN: A longitudinal descriptive study (1984-9). SETTING: A private primary care and STD clinic in Sydney, Australia. SUBJECTS: 88 homosexual men documented to seroconvert to HIV-1, and 37 homosexual controls who had practised unprotected anal intercourse with another man known to be HIV-1 positive but who remained HIV-1 negative. MAIN OUTCOME MEASURE: Incidence of bullous impetigo. RESULTS: The crude annual incidence of bullous impetigo was 0.015 in subjects while they remained HIV-1 negative (10 cases) and 0.045 in early HIV-1 positive subjects (2 cases). Overall, 9% of the HIV-1 seroconverters and 9% of the HIV-1 negative controls were documented as suffering bullous impetigo over a mean of 29.2 and 39.3 months, respectively. CONCLUSIONS: Bullous impetigo in an adult could prove to be a clinical indication that a person is either infected with HIV-1 or is in close (possibly sexual) contact with a person with HIV-1 infection. If true, the recognition of bullous impetigo could provide an opportunity for behavioural intervention to limit the spread of HIV-1.
Australia↗
Streptococcal impetigo and acute glomerulonephritis in children in Cairo.
Impetigo contagiosa in Cairo affected young children of both sexes, the face being the main site. Post-impetigo nephritis, confirmed by a low serum C3 level and by urinalysis, occurred in only 11% of cases. Streptococcus pyogenes strains were recovered from 84% of the skin lesions. Sixteen types were identified according to their T-protein, and most infections were associated with T3/B3264, T13/B3264, T5, T11, T12, T8/25/Imp 19 and T14/49; the majority of these types were also recovered from houseflies. The types isolated from cases of post-impetigo nephritis were T4 (M 60), T14/49 (M49), T8/25/Imp 19 (mostly M 55) and T11. Seventy percent of the patients infected with T4 (M 60) and 40% of those infected with T14/49 (M 49) developed nephritis. Strains isolated from the skin bore a closer resemblance to those isolated from the nose than to those found in the throat. The ASO response was poor in uncomplicated impetigo but the titre rose more aften in post-impetigo nephritis.
Acute Disease↗
Group A streptococcal pharyngeal carriage, pharyngitis, and impetigo in two northern Canadian native communities.
The prevalence of pharyngeal carriage of group A streptococci, streptococcal pharyngitis, and impetigo was determined in schoolchildren in two northern communities, one Inuit (mean number of schoolchildren surveyed, 233) and one native Indian (mean number of schoolchildren surveyed, 349). At three surveys from November 1984 to May 1985, pharyngeal group A streptococcal carriage was 5.3%, 22%, and 34% in the Inuit community and 5.3%, 5.1% and 10% in the native Indian, with impetigo prevalence 1.6%, 3.8% and 1.0%, and 2.4%, 4.2% and 0.6%, respectively. Increased pharyngeal carriage correlated with the increasing number of household residents and the lower school grade. In 12 months of observation the incidence of group A streptococcal pharyngitis was 49/100 schoolchildren for the Inuit and 9.4/100 for the native Indian community, with impetigo 13/100 and 11/100 respectively. The maximal incidence of pharyngitis was late winter in the Inuit community and midsummer in the native Indian. The incidence of impetigo peaked in January for both communities. M and T typing showed consecutive outbreaks of different serotypes in the Inuit community, but a persistent low level of endemic infection in the Indian community. These observations suggest a seasonal prevalence of group A streptococcal pharyngeal carriage consistent with other North American populations, but marked inter-community variation in pharyngeal carriage and disease. The midwinter peak of impetigo appears unique to these populations.
Adolescent↗
Impetigo herpetiformis as a cause of postpartum fever.
Impetigo herpetiformis is a rare and often serious pustular dermatosis of pregnancy. The usual course of impetigo herpetiformis is one of continued progression throughout pregnancy with rapid resolution during the puerperium. This patient is the first reported case, to the authors' knowledge, of impetigo herpetiformis presenting during the puerperium, a time usually associated with the disease's remission. This suggests that impetigo herpetiformis should be included in the differential diagnosis of puerperal fever, particularly in those cases associated with dermatoses.
Abdomen↗
Treatment of impetigo: a review.
A number of well-designed comparison studies have shown the superiority of oral or injectable antibiotics over typical treatment in the treatment of impetigo contagiosa. Erythromycin, phenoxymethyl penicillin, intramuscular benzathine penicillin G as well as clindamycin, cefaclor and amoxicillin with clavulanic acid have been shown to be extremely effective. Because of significant differences in study design, it is difficult to compare drugs investigated in different studies. Intramuscular benzathine penicillin G consistently has been associated with the highest cure rates, especially in studies specifically of streptococcal impetigo. It is unclear whether these high cure rates reflect superior efficacy or are the result of lesser compliance with oral medication, but the latter explanation is quite likely. This information generally translates into daily practice as a recommendation of a penicillin or an erythromycin preparation for streptococcal impetigo unless the lesions are small and few in number, in which case topical therapy is probably sufficient. If oral antibiotics are prescribed they should be given for 10 days. Systemic as opposed to topical antibiotics should be considered more strongly in situations where the incidence of impetigo is high, since these drugs are clearly superior in sterilizing the lesions quickly to prevent transmission. Other situations that favor the use of systemic as opposed to topical antibiotics include the presence of nephritogenic strains in the population, whether endemic or epidemic, more severe or spreading lesions and a population with poor hygiene.
Administration, Oral↗
Treatment of impetigo and ecthyma. A comparison of sulconazole with miconazole.
In a randomized, double-blind, parallel comparative study of 80 patients, impetigo and ecthyma were treated effectively by sulconazole nitrate 1% cream and miconazole nitrate 2% cream applied to lesions twice daily for 14 days. When treatment began, bacterial cultures from all pyodermal lesions yielded Group A beta-hemolytic streptococci or pathogenic staphylococci. Among the 32 sulconazole-treated impetigo patients, bacterial cultures from 26 (69%) were negative by treatment day 4, and those from all 32 (100%) were negative by treatment day 7; among the 34 miconazole-treated impetigo patients, cultures from 17 (50%) were negative by treatment day 4, cultures from 32 (94.1%) were negative by treatment day 7, and cultures from 29 (97%) were negative by treatment day 14. Each treatment promptly relieved the pyodermal signs (crusts, vesicles, pustules, bullae, and exudate). Both agents were considered to be safe and effective medications for treating impetigo and ecthyma.
Double-Blind Method↗
Streptococcal types in impetigo and acute glomerulonephritis among children in Addis Ababa.
Studies on the streptococcal epidemiology of impetigo in children below 12 years of age in Addis Ababa indicated that most streptococci isolated belonged to the classic serological impetigo strains. Streptococcal type 9 seemed to be a new impetigo strain. Several cases of severe acute glomerulonephritis on impetigo basis were observed during the study.
Acute Disease↗
[Erysipelas and impetigo].
Erysipela is a dermal or hypodermal infection of the skin, which predominantly involves the leg and is associated with high fever. Erysipela is most often caused by Streptococcus pyogenes. Venous insufficiency or lymphoedema are important local factors for the development of this infection which spreads from intertrigo, local wound or leg ulcer. Treatment is essentially based on parenteral penicillin G. Impetigo is a superficial infection of the skin due to Staphylococcus aureus or to Streptococcus pyogenes, and is frequent in children. Classical impetigo is made of yellow-brown crusts located around the mouth and nose, whereas bullous impetigo involves frequently the trunk and limbs. Secondary impetigo occurring in pediculosis or scabiosis is frequent. It is a contagious disease which is more frequent in patients with poor hygiene. It can be treated by general antibiotics, mainly macrolides, penicillin M or cephalosporins.
Adult↗
Impetigo. Current etiology and comparison of penicillin, erythromycin, and cephalexin therapies.
We attempted to determine the causative bacterial pathogens of impetigo in children in our area, to compare the effectiveness of three frequently used oral antimicrobial treatment regimens, and to correlate the antimicrobial sensitivity of the bacterial isolates with clinical responses to treatment. Seventy-three children with impetigo were randomly assigned to receive penicillin V potassium or cephalexin monohydrate, both administered in dosages of 40 to 50 mg/kg per day, or erythromycin estolate administered in a dosage of 30 to 40 mg/kg per day. All drugs were given in three divided doses for 10 days. Treatment failure was defined as persistence of lesions 8 to 10 days after initiation of drug therapy as determined by examiners blinded to the treatment therapies. Forty-five (62%) cultures showed Staphylococcus aureus only, 14 (19%) showed S aureus and group A beta-hemolytic streptococci, six (8%) showed group A beta-hemolytic streptococci only, and eight (11%) showed no growth or other organisms. Treatment failure occurred in six (24%) of 25 patients treated with penicillin V, one (4%) of 25 patients treated with erythromycin estolate, and no patients treated with cephalexin. We conclude that S aureus is the most common cause of impetigo in children in our study population, that cephalexin is the most effective treatment, that erythromycin estolate is nearly equally effective and may be preferred on a cost-effectiveness basis, and that penicillin V is inadequate for treatment of this infection.
Adolescent↗
Production of experimental staphylococcal impetigo in mice.
We produced a staphylococcal impetigo model by epicutaneous inoculation in mature mice. A strain isolated from a human impetigo was used. Five-week-old female mice (ddy-strain) were used with and without pre-treatment by cyclophosphamide (Cy) (2 mg/mouse) for 5 days. The back skin of mice was shaved by a razor blade and slightly abraded by sand paper. Bacterial suspension (1.4 x 10(7) CFU/0.05 ml) was applied on the abraded areas which were then occluded under sterile plastic plaster. Although intraepidermal blisters developed in non-Cy-treated mice, massive neutrophil infiltration obscured the changes there. Development of subcorneal bullae in Cy-treated mice inoculated with Staphylococcus aureus was first observed at 3h and enlargement of bullae was apparent at 12 h after inoculation. The bullae produced in Cy-treated mice contained numerous S. aureus bacilli. Electronmicroscopically, S. aureus cells invaded the horny layer at 1/4 h. A clear halo was seen between S. aureus cells and horny cells. S. aureus cells attached to surrounding horny cells by fibril-like structures. The halo-like spaces became larger, coalesced and then developed into an intraepidermal blister. Our new method to produce human impetigo-like blister in Cy-treated adult mice may contribute to disclosing the mechanisms of blister formation in epidermis by S. aureus. Due to the thin structure of mouse epidermis, only specimens taken earlier than 24 h after inoculation were considered appropriate.
Animals↗
Production of staphylococcal impetigo-like lesion on human skin explants in culture.
We produced a highly reproducible experimental impetigo-like lesion in normal human skin explants in culture. The three Staphylococcus aureus strains we used were an isolate from a human impetigo (E strain), an isolate from a human furunculosis (N strain) and ATCC 29213 strain. E strain was a protein A positive, coagulase type V, producer of exfoliative toxin (ET) and beta-toxin. N strain was a coagulase type IV, ET non-producer and alpha-toxin positive. ATCC 29213 was a coagulase type II, ET non-producer, and alpha-, beta-, and delta-toxin positive. Normal human skin samples were obtained from 8 adult skin surgery patients. One specimen was obtained from human oral mucosa. Small pieces of the samples were slightly abraded on the epidermal surface and cultured on lens paper rafts floating in Eagle's Minimum Essential Medium in an atmosphere of 5% CO2 and 95% air. Fifty microliters of the respective bacterial suspensions were applied to the epidermal surfaces of the explants. The inoculated surfaces were then occluded under sterile plastic plaster. Histologically, the formation of intraepidermal blisters at the granular layer level with acantholytic cells was observed in all 8 of the skin specimens at 10 h after inoculation with E strain. The specimen from an oral mucous membrane did not produce similar changes with any of the three S. aureus strains. Neither N or ATCC strains developed bullae in the epidermis at 6, 10 or 18 h after inoculation. Immunofluorescent examination revealed that the inner surfaces of blisters in the epidermis were lined with anti-ETA antibody. Under the electron microscope, the blisters of the specimens which had been inoculated with strain E contained only a few S. aureus cells. These results suggest that blister formation at the granular layer level with acantholytic cells is mediated by ET action at the granular layer level and occurs without invasion of lymphocytes or neutrophils, or the involvement of any serum components. Therefore, under appropriate conditions, impetigo could develop even in adults.
Adult↗
Epidemic bullous impetigo in a nursery due to a nasal carrier of Staphylococcus aureus: role of epidemiology and control measures.
From September 14, 1981 to February 28, 1982, an epidemic of bullous impetigo caused by a penicillin/tetracycline resistant strain of Staphylococcus aureus, phage type 3A/3C, occurred in a newborn nursery in Louisville, Kentucky. Twenty of 1,181 (1.7%) infants at risk developed disease during the six-month epidemic period. Clinically all case-infants had bullous impetigo skin lesions. One infant developed staphylococcal septicemia. No infant died. An epidemiologic investigation identified a nurse as having significantly greater contact with case-infants than control-infants (p = 0.0013). She was also found to be a nasal carrier of the epidemic strain. Infection control measures appeared to decrease infant-to-infant transmission via the hands of non-colonized nurses, but did not affect transmission from the nurse carrying the epidemic strain to infants. No cases of bullous impetigo have occurred since this nurse was temporarily removed from the nursery for treatment.
Anti-Bacterial Agents↗
Impetigo herpetiformis and pustular psoriasis during pregnancy.
Impetigo herpetiformis and pustular psoriasis during pregnancy are distinct diseases. Pustular psoriasis during pregnancy is indistinguishable clinically, genetically, and histologically from pustular psoriasis in women who are not pregnant. Impetigo herpetiformis is not a heritable disorder and is not found particularly in persons with a personal or family history of psoriasis. Histologically in impetigo herpetiformis there are many large mononuclear cells in the dermis and in epidermal pustules. Proliferation of these mononuclear cells in the dermis is intense.
Autoradiography↗
Impetigo contagiosa III. Comparative efficacy of oral erythromycin and topical mupirocin.
Ninety-seven patients with impetigo were prospectively enrolled in a study to determine the comparative efficacy of systemic and topical antibiotic therapy. After obtaining a bacterial culture from a representative lesion, the children were randomized to receive seven days of either oral erythromycin or topical mupirocin administered three times daily. Staphylococcus aureus alone was isolated from 51% and in association with group A beta-hemolytic streptococci (GABS) from 29%; GABS alone was isolated from 4% of patients. Of 48 children who received erythromycin, 43 (90%) were clinically improved or cured, and 11 of 17 were bacteriologically cured. Of 49 children who received mupirocin, 47 (96%) were clinically improved or cured, and 10 of 14 were bacteriologically cured. At three-week follow-up, clinical cure rates and number of secondary household cases of impetigo were equivalent in both treatment groups. Mupirocin appears to be a well-tolerated, albeit expensive, alternative to erythromycin for the treatment of impetigo.
Administration, Oral↗
Randomized clinical trial of topical mupirocin versus oral erythromycin for impetigo.
The safety and efficacy of a new topical antiinfective agent, mupirocin, was compared with that of oral erythromycin ethylsuccinate in the treatment of impetigo in children. Sixty-two children aged 5 months to 13 years with impetigo were assigned to be treated with either mupirocin in three daily applications or erythromycin ethylsuccinate (40 mg/kg of body weight per day divided into four doses) according to a randomized treatment schedule. On the initial visit, exudate or cleansed infected sites or both were cultured and therapy was begun. All patients were treated for 8 days. Patients were seen again on days 4 to 5 of therapy, at the end of therapy, and 7 days after the end of therapy. Sites of infection were comparable between the groups, as were bacteriologic responses. At the first visit, 24 of 30 children in the mupirocin group and 14 of 32 children in the erythromycin group were cured or had at least a 75% reduction in size of the lesions. At the end of the study, all 29 of the children in the mupirocin group who came to follow-up, compared with 27 of 29 in the erythromycin group, were cured. Side effects were few. Five children in the erythromycin group developed mild diarrhea. Thus, mupirocin appears to be safe and effective in treating impetigo in children. Our data show a trend toward more rapid clinical response with mupirocin than with erythromycin.
Administration, Oral↗