Published on in Vol 4, No 2 (2021): Jul-Dec

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From the Cochrane Library: Interventions for Impetigo

From the Cochrane Library: Interventions for Impetigo

From the Cochrane Library: Interventions for Impetigo

Research Letter

1Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States

2Dermatology Service, Rocky Mountain Regional VA Medical Center, Aurora, CO, United States

Corresponding Author:

Ani Oganesyan, BA

Department of Dermatology

University of Colorado Anschutz Medical Campus

13001 E 17th Place

Aurora, CO, 80045

United States

Phone: 1 818 441 6860


Impetigo is a contagious, superficial skin infection, most commonly affecting children, caused by Staphylococcus aureus, group A beta-hemolytic streptococcus (Streptococcus pyogenes), or both pathogens in combination [1]. Bacteria infect the epidermis, leading to itchy or painful, yellow-crusted, erythematous plaques. If blisters are present, the infection is referred to as bullous impetigo [2]. While untreated impetigo is often self-limited, treatment is important for symptom control, limiting the spread of infection and minimizing the risk of developing life-threatening complications. Due to the prevalence and risks associated with impetigo, evidence-based research to inform treatment guidelines is critical to decreasing its disease burden [1].

Current treatment options for impetigo, summarized in Table 1, include topical and systemic antibiotics, as well as topical disinfectants [2]. A 2012 Cochrane review, “Interventions for Impetigo” [2], assessed 68 randomized controlled trials (26 oral treatments and 24 topical treatments for the management of primary impetigo). Specifically, various management strategies were evaluated: watchful waiting, topical disinfectants (saline, hexachlorophene, povidone-iodine, chlorhexidine), topical antibiotics (neomycin, bacitracin, polymyxin B, gentamycin, fusidic acid, mupirocin, retapamulin, topical steroid/antibiotic combination), and systemic antibiotics (penicillin, [flu]cloxacillin, amoxicillin/clavulanic acid, erythromycin, cephalexin). Primary outcome measures included an assessment of clearance of crusts, blisters, and redness, as well as resolution of associated symptoms.

Table 1. Current guidelines for the management of impetigo.
TreatmentDosing and usageEvidence gradea
Topical antibiotics

Mupirocin 2% ointment3 times daily for 5-7 daysStrong recommendation

Retapamulin 1% ointment2 times daily for 5 daysStrong recommendation

Fusidic acid 2% cream3 times daily until healed or up to 14 daysNot available in the United States
Oral antibiotics

Dicloxacillin, 250 mg; cephalexin, 250 mg4 times daily for 7 days for empiric therapy in adultsStrong recommendation

Cephalexin, 250 mg4 times daily for 7 days for empiric therapy in adultsStrong recommendation

Cephalexin, 25-50 mg/kg/day3-4 divided doses for empiric therapy in childrenStrong recommendation

PenicillinIf culture yields streptococci aloneStrong recommendation

Doxycycline, clindamycin, or trimethoprim-sulfamethoxazoleIf methicillin-resistant Staphylococcus aureus (MRSA) is suspected or confirmedStrong recommendation

aRecommendation according to the Infectious Diseases Society of America, using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system’s strength of recommendation: strong recommendation (desirable effects clearly outweigh undesirable effects or vice versa) and weak recommendation (desirable effects closely balanced with undesirable effects, or [with low- or very low–quality evidence] uncertainty in the estimates of desirable effects, harms, and burden so they may be closely balanced).

Topical antibiotics (mupirocin, retapamulin, fusidic acid) were found to be more effective than the placebo and preferable to oral antibiotics for limited impetigo. Topical antibiotics were also superior to disinfection methods. No significant differences were found in studies evaluating oral antibiotics, with the exception that penicillin was less effective than most other antibiotics. Due to insufficient evidence, the efficacy of these treatments for patients with more extensive disease could not be established. However, newer data suggest systemic antibiotics are more efficacious for patients with 5 or more lesions, or with oral or deep tissue involvement [3]. Significant findings pertaining to the treatment comparisons in this review are summarized in Table 2.

Of note, the authors of the Cochrane review pointed to a lack of evidence regarding impetigo treatment in developing countries and endemic populations—a significant data gap given that impetigo disproportionately affects children in resource-poor communities and has the highest prevalence among Australian Aboriginal children (up to 49%). A recent systematic review [4] provided much-needed insight, calling for research into topical antimicrobials for impetigo as alternatives to current first-line therapy (oral co‐trimoxazole and intramuscular benzathine penicillin G) in rural Australia. Currently, there are no trials of topical antibiotics for impetigo in high-burden settings, highlighting the need for further studies.

Table 2. Treatment comparison with respective results, risk ratio (RR), 95% CI, and number of studies and participants.
Topical antibiotic vs placeboInvestigator assessmentTopical antibiotic was superiorRR 2.24, 95% CI 1.61-3.13; 6 studies, n=575
Topical mupirocin vs topical fusidic acidInvestigator assessmentNo differenceRR 1.03, 95% CI 0.95-1.11; 4 studies, n=440
Topical mupirocin vs oral erythromycinInvestigator assessmentTopical mupirocin was superiorRR 1.07, 95% CI 1.01-1.13; 10 studies, n=581
Penicillin vs erythromycinInvestigator assessmentErythromycin was superiorRR 1.29, 95% CI 1.07-1.56; 2 studies, n=79
Penicillin vs cloxacillinInvestigator assessmentCloxacillin was superiorRR 1.59, 95% CI 1.21-2.08; 2 studies, n=166
Topical antibiotics vs disinfecting treatmentsInvestigator assessmentTopical antibiotic was superiorRR 1.15, 95% CI 1.01-1.32; 2 studies, n=292

In industrialized settings, data continue to support the use of topical mupirocin and retapamulin as first-line treatments for primary impetigo. Current guidelines (Table 1) recommend topical antibiotics as the initial therapy for most patients. In patients with numerous lesions, ulceration into the dermis, or in outbreaks affecting several people, oral antibiotics are preferred [5].

The commonality of impetigo and its rapidly changing antibiotic resistance patterns make it a moving target. Its contagious nature and associated morbidity further emphasize the need for updated guidelines.

Editorial Notice

The views expressed in this paper are those of the authors and in no way represent the Cochrane Library or Wiley.

This article is based on a Cochrane Review previously published in the Cochrane Database of Systematic Reviews 2012, Issue 1, DOI:10.1002/14651858.CD003261.pub3 (see for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review.

Conflicts of Interest

RD is editor in chief of JMIR Dermatology, a joint coordinating editor for Cochrane Skin, a dermatology section editor for UpToDate, a social media editor for the Journal of the American Academy of Dermatology (JAAD), and a podcast editor for the Journal of Investigative Dermatology (JID). He is a coordinating editor representative on Cochrane Council and Cochrane Council cochair. TS is a section editor for JMIR Dermatology.

RD receives editorial stipends (JAAD, JID), royalties (UpToDate), and expense reimbursement from Cochrane Skin. TS receives fellowship funding from the Pfizer Global Medical Grant (58858477) Dermatology Fellowship 2020 (principal investigator: author RD) and serves on the Medical Advisory Board of Antedotum Inc.

  1. Hartman-Adams H, Banvard C, Juckett G. Impetigo: diagnosis and treatment. Am Fam Physician 2014 Aug 15;90(4):229-235 [] [Medline]
  2. Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LWA, Morris AD, Butler CC, et al. Interventions for impetigo. Cochrane Database Syst Rev 2012 Jan 18;1:CD003261 [] [CrossRef] [Medline]
  3. Nardi NM, Schaefer TJ. Impetigo. Treasure Island, FL: StatPearls Publishing; 2021.
  4. May PJ, Tong SYC, Steer AC, Currie BJ, Andrews RM, Carapetis JR, et al. Treatment, prevention and public health management of impetigo, scabies, crusted scabies and fungal skin infections in endemic populations: a systematic review. Trop Med Int Health 2019 Mar;24(3):280-293 [] [CrossRef] [Medline]
  5. Impetigo (updated Nov 30, 2018). DynaMed. Ipswich, MA: EBSCO Information Services; 1995. URL: [accessed 2021-10-30]

Edited by G Eysenbach; submitted 07.09.21; peer-reviewed by J Solomon, F Wallnöfer; comments to author 21.10.21; revised version received 31.10.21; accepted 22.11.21; published 03.12.21


©Ani Oganesyan, Torunn Sivesind, Robert Dellavalle. Originally published in JMIR Dermatology (, 03.12.2021.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Dermatology Research, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.