Impetigo

Impetigo is a surface infection of the skin caused by everyday bacteria — usually Staphylococcus aureus, sometimes a Streptococcus — getting in through a tiny break: a graze, an insect bite, a cold sore, a scratched patch of eczema, even skin left raw by a runny nose. It is one of the most common skin infections seen in children, it spreads fast through households, nurseries and classrooms, and it is one of the seven conditions our pharmacists in Timperley can assess and treat under NHS Pharmacy First for anyone aged one and over.

Why impetigo takes hold, and who gets it

The bacteria behind impetigo live harmlessly on many people’s skin and in their noses. Trouble starts when they reach broken skin, where they multiply and produce toxins that split the top layer. Children are affected most because they play close together, touch their faces constantly and pick at scabs. Warm, humid weather, crowded settings and a background skin condition such as eczema all raise the odds. Adults catch it too, often from a child in the house, or through contact sports.

Non-bullous or bullous — why the distinction matters

Most impetigo is non-bullous. It begins as a small, thin-walled blister on a red base that bursts almost immediately — so quickly that people rarely notice the blister stage. What they see is the weeping sore and then the golden, honey-coloured crust that thickens over a day or two. Satellite spots appear nearby when the fluid is spread by fingers. It is usually not painful, though it can itch.

Bullous impetigo is less common. The blisters are larger — often 1–2 cm across — floppy and fluid-filled, and they can hang around for two or three days before rupturing to leave a flat, brownish crust. Because bullous impetigo behaves differently and is more likely to affect babies and to spread, the Pharmacy First pathway does not cover it; the pharmacist will refer you to a prescriber promptly rather than treat it in the pharmacy.

Conditions that are easily mistaken for impetigo

Several rashes can mimic impetigo, and telling them apart is a large part of the consultation:

• Cold sores cluster on the lip edge, start with tingling, and blister before crusting — although impetigo can grow on top of a cold sore.
• Infected eczema is red, raw and weepy over a wider area, and the patient usually has known eczema flaring.
• Chickenpox brings small blisters in crops across the body with a fever.
• Ringworm forms a ring with a scaly edge and a clearer centre.
• Insect bites that have become infected are hot, swollen and painful rather than crusted.
• Scabies is intensely itchy, worse at night, with burrows between fingers.

The pharmacist checks the pattern of spread, the type of crust, where the lesions sit and how long they have been there. If the picture does not fit impetigo, they will tell you what it more likely is and where to go next.

What happens in the consultation

Impetigo is diagnosed by looking at the skin under good light, so you will be seen in person; a photo or phone description is not enough. You do not need to see a GP first — simply come in or ask at the counter. The pharmacist will:

1. Ask when the sores appeared, how they have changed, whether anyone else at home has them, and whether this has happened before this year.
2. Examine the skin and count the affected patches. Three or fewer spots or clusters counts as localised; four or more is widespread. This number steers the treatment decision.
3. Check for anything that moves you outside the pathway (see below) and for signs of a deeper infection.
4. Ask about allergies, current medicines, pregnancy and any long-term conditions that affect immunity.
5. Agree a plan, supply treatment where appropriate, and record the consultation so your GP practice is updated.

Age limits and exclusions on the impetigo pathway

Pharmacy First covers non-bullous impetigo in children from their first birthday and in adults who are otherwise well. The pharmacist will arrange onward care instead of treating in the pharmacy if:

• the child is under one — babies need a doctor’s assessment;
• the impetigo is bullous;
• this is a recurrent episode (two or more in the same year), because recurrence suggests a hidden reservoir of bacteria that needs swabbing and a different approach;
• the person is immunosuppressed — for example on chemotherapy, biologic medicines or long-term steroid tablets — and the impetigo is widespread;
• the person is systemically unwell with fever, shivering or feeling generally ill;
• the person is pregnant and under 16;
• a full course of treatment for this same episode has already failed to clear it.

Beyond those rules the pharmacist uses judgement, and may ask a prescriber to take over where impetigo sits on top of a flaring skin condition such as uncontrolled eczema or scabies, where there is a known history of MRSA, or where a breastfeeding parent has sores on the breast.

These are not arbitrary rules — each marks a situation where impetigo is more likely to spread, come back or hide something more serious.

How the pharmacist chooses a treatment

The decision follows NICE guidance and the national pathway, in steps. For localised impetigo the first choice is a topical antiseptic cream, which the evidence shows works about as well as a topical antibiotic while sparing antibiotics for when they are really needed. A topical antibiotic is used instead if the antiseptic is unsuitable — for instance, sores close to the eyes — or if a course of antiseptic has not worked and the infection is still localised. For widespread impetigo the pharmacist can supply an oral antibiotic, with an alternative class if you are allergic to penicillin. Topical and oral antibiotics are not used together. Whatever is supplied, the pharmacist will show you how to apply or take it and remind you to finish the course even once the crusts have gone.

How quickly impetigo clears

With treatment, most people see the sores dry and stop spreading within two to three days and clear fully in around a week. Without treatment impetigo often resolves by itself, but it can take two to three weeks and stays contagious throughout. The crusts fall away as the skin underneath heals, and it does not normally scar, though a patch of pink or slightly darker skin can linger for a few weeks. If the sores are still spreading or new ones keep appearing once the course has finished, come back or contact your GP — the diagnosis or the treatment needs a second look.

Stopping it spreading at home

Because the bacteria travel in the fluid from the sores, hygiene is as important as the cream or tablets:

• Wash the affected skin gently with soap and warm water and pat dry with a disposable towel or a flannel that goes straight in the wash.
• Wash hands thoroughly after touching the sores or applying cream; use a cotton bud or a gloved finger rather than a bare fingertip.
• Keep nails short and try to stop children scratching or picking crusts.
• Do not share towels, flannels, bedding, razors or pillows. Wash them at 60 °C.
• Wipe down toys, and wash any bedding or clothing that has touched the sores.
• Avoid preparing food for others while sores are uncovered.
• Loosely cover sores with a dressing if possible, especially before contact sports.

Nursery, school and work: when it is safe to go back

UK Health Security Agency guidance says children need to stay off school or nursery until all the sores have crusted over and dried, or until 48 hours after starting antibiotic treatment. NHS advice applies the same 48-hour rule to the antiseptic cream. The same principle is sensible for adults, particularly anyone working with food, in healthcare or with young children.

When impetigo needs a doctor the same day

Call 999 or go to A&E if there is a high fever with drowsiness or confusion, skin that is peeling in sheets, or a rapidly spreading area of hot, swollen, painful skin. Contact your GP or NHS 111 the same day if the redness is spreading beyond the crusted sores, the person develops a fever, the sores are becoming very painful or filled with pus, or there is no improvement after finishing the course. Babies under one with any suspected impetigo should always see a doctor.