Recommendation ID

For which people with impetigo are antiseptics as effective as antibiotics?

Any explanatory notes
(if applicable)

Why the committee made the recommendations
Recommendations 1.1.2 to 1.1.6

The evidence showed that impetigo was cured or improved with a placebo in some people. However, impetigo is highly infectious, and the committee agreed that treatment is important to limit the spread of infection and the worsening of symptoms, and to hasten recovery. A faster recovery is also likely to mean less time off school, nursery or work.

It was not clear in the evidence reviewed if impetigo was localised or widespread. The committee agreed that different treatment options are appropriate for impetigo based on the type and extent of the infection. It agreed that clinical judgement should be used to determine whether impetigo is localised or widespread.

Localised non-bullous impetigo
The evidence suggested that hydrogen peroxide 1% cream (a topical antiseptic) is as effective as a topical antibiotic for treating impetigo. Impetigo was cured or improved in a large proportion of people using hydrogen peroxide. The committee noted this evidence came from 1 randomised controlled trial. Based on its experience, the committee agreed that the risk of adverse effects from hydrogen peroxide at 1% concentration, such as irritation and skin bleaching, are minimal. They also agreed that the significance of this is especially low when compared with the risk of adverse effects associated with topical antibiotics, such as rapid development of antimicrobial resistance.

The committee was aware that the use of hydrogen peroxide 1% cream for impetigo is a change in practice and health professionals may not be familiar with its use. It noted that some other topical antiseptics are licensed for superficial skin infections, which may be cheaper and more widely available. However, no evidence was identified for treating impetigo with other topical antiseptics, so the committee could not make a recommendation for their use. Based on the available evidence, the committee agreed that the long-term benefits of good antimicrobial stewardship, in combination with the low risk of adverse events compared with using a topical antibiotic, outweighed the additional cost of hydrogen peroxide 1% cream.

Overall, the evidence showed that a topical antibiotic was as effective as an oral antibiotic for curing or improving impetigo. Based on the evidence and its experience, the committee agreed that topical antibiotics would cause fewer adverse effects than oral antibiotics, and that applying a topical antibiotic is usually straightforward for localised impetigo. The committee discussed its experience of antimicrobial resistance with topical antibiotics compared with oral antibiotics. It agreed that the likely increased risk of resistance with topical antibiotics applied to a localised area of impetigo for a short duration was outweighed by the increased risk of adverse events with oral antibiotics. The committee therefore agreed that if hydrogen peroxide 1% cream is unsuitable, for example, because impetigo is around the eyes, a topical antibiotic should be offered for people who are not systemically unwell or at high risk of complications.

Widespread non-bullous impetigo
Based on its experience, the committee agreed that people with widespread non-bullous impetigo should be offered a short course of either a topical or an oral antibiotic. They discussed that the choice of topical or oral use would be an individualised clinical decision, taking local antimicrobial resistance data into account alongside patient preference, practicalities of administration, possible adverse effects and previous use.

The committee discussed that effectively applying a cream may be difficult over larger skin areas. It agreed that an oral antibiotic may be a better option for some people with widespread non-bullous impetigo, despite the higher risk of adverse events, and that the decision should be based on a discussion of the person's preferences and the balance of risks and benefits. Antimicrobial resistance can develop rapidly with the use of topical antibiotics, and the committee agreed that repeated doses or extended use of the same topical antibiotic should be avoided.

Bullous impetigo or impetigo in people who are systemically unwell or at high risk of complications
The evidence on treating bullous impetigo was limited to a small study in newborn babies. From its experience, the committee discussed that the presence of bullae may mean that a topical antibiotic is unable to reach the infected area. Therefore, it agreed that an oral antibiotic is needed to target the infection adequately.

No evidence was identified for treating people who are systemically unwell or at higher risk of complications. Based on its experience of current practice, and because of the high risk of harm if topical application of antibiotic is inadequate, the committee agreed that this population should be offered an oral antibiotic. People at higher risk of complications can include, for example, people who are immunocompromised or have coexisting skin conditions.

Combination treatment
The evidence suggested that combination treatment with an oral and topical antibiotic was no more effective than a topical antibiotic alone. The committee agreed that combination treatment should be discouraged because of the increased risk of adverse events and antimicrobial resistance.

Research recommendation
The committee agreed that further research is needed to more clearly show which populations would benefit from antiseptic treatment. A research recommendation was developed to encourage more research in this area, which may contribute to future antibiotic-sparing recommendations and help reduce the risk of resistance and adverse events with antibiotics.

Source guidance details

Comes from guidance
Impetigo: antimicrobial prescribing
Date issued
February 2020

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 29/02/2020