Pharmacy First: Top tips for managing non-bullous impetigo

CLINICAL UPDATE

Most community pharmacies in England now running the Pharmacy First service which enables them to diagnose and treat seven specific conditions. Under the service, pharmacists can prescribe set medications where appropriate, without recourse to a GP. This will hopefully reduce some of the current pressures on general practice.

This series of guides assumes that pharmacists are familiar with the clinical pathways and requirements for Pharmacy First. The articles explore some key aspects of each service to support and enhance pharmacists’ knowledge.

In this, our second in the series, GP Dr Toni Hazell provides her tips on diagnosing and treating non-bullous impetigo in adults and children over the age of one.  

Impetigo

Impetigo is a common bacterial infection of the skin. It is most common in young children, with 2.8% of those aged up to four having an outbreak each year, but can also occur in adults.¹ It might present on otherwise healthy skin, or as a complication of an acute or chronic skin condition such as chickenpox, eczema or scabies. It can present with or without bullae (blisters) – if these are present, then the patient shouldn’t be seen within Pharmacy First and should be signposted to their GP.

Here are my tips on how to assess and manage presentations of non-bullous impetigo in those aged one or over appropriately and in line with the new Pharmacy First service.

1. Check the patient isn’t unwell – and take a full history

It is always important to consider if a patient is unwell enough that they may need hospital treatment. As with all the Pharmacy First services, the clinical pathway advises pharmacists to consider calculating a NEWS2, an early warning score for sepsis. However, as explained in a previous article in this series, NEWS2 is not validated in primary care and should not be relied on in isolation.² It is important to develop a feeling for when a patient looks unwell, backed up by physiological measurements.

I would be concerned if a patient looks sweaty or feels dizzy, is tachycardic or has a low blood pressure. In the context of impetigo on the face, any infection that appeared to involve the skin and soft tissue around the eye might prompt assessment in hospital. The flowchart also mentions deeper soft tissue infection as something to look out for – the main risk here is of cellulitis, which would cause more a more extensive and spreading area of skin that is red, painful, hot and swollen, often accompanied by systemic features such as a fever or general malaise.

It is important to also take a full history about medical conditions and medication – a patient who is immunosuppressed due to medical history (eg, a blood cancer) or due to medication (taken, for example, post-transplant or rheumatoid arthritis) – may develop a more widespread infection and need referring on.

2. Recognise the key non-bullous impetigo features

Impetigo is a clinical diagnosis, made on appearance, without the need for any tests. As above, you first need to rule out bullous impetigo, as this should be referred to a GP.  Bullous impetigo is not precisely defined by a number or size of blisters, but the blisters do not burst easily so will often be visible when someone presents (see image 1).^3,4 If blisters are seen when someone comes in for a Pharmacy First appointment, they should be referred back to their GP, or other appropriate source of advice depending on local pathways.

Image 1: Bullous impetigo – blister on the finger (Science Photo Library)

In non-bullous impetigo, thin-walled pustules or vesicles appear, which burst quickly and so have usually gone by the time that the patient is seen. On bursting, the pustules release a fluid which dries on the skin to cause a gold or yellow-brown crust which gets thicker with time and might be itchy (though not everyone feels an itch).⁴ The most common place for lesions is on the face (see image 2 below), but if they are scratched, and another part of the skin is then touched, the infection might be transferred elsewhere. This is particularly likely if there is a break in the skin. A temperature is unusual and indicates a more severe case of impetigo.¹

See box 1 for key features that distinguish bullous and non-bullous impetigo.

Box 1 Key distinguishing features of bullous and non-bullous impetigo⁴

Bullous impetigo

• Blisters usually spread locally on the face, trunk, extremities, buttocks or perineal regions and may reach distal areas.
• Blisters less easily ruptured than in the non-bullous form. Initially contain clear fluid, which then becomes cloudy. Once ruptured, brown-yellow crusts develop.
• Unlike with non-bullous form, lesions can spread as the centre of the lesion clears.
• Buccal mucous membrane can be involved.

Non-bullous impetigo

• Multiple lesions usually on exposed sites such as face (particularly around the nose and mouth) and limbs, or in the flexures, especially the axillae.
• Blisters very thin-walled and rupture easily, so rarely presents with blisters.
• Exudate dries to form golden yellow or yellow-brown crusts.
• Lesions spread gradually without central healing.
• Mucosal involvement uncommon.

3. Consider other possible differential diagnoses

The Pharmacy First flowchart suggests that if the lesion doesn’t seem similar to that described in point 2, that you consider an alternative diagnosis and proceed appropriately.

Crusting on the face is fairly typical of impetigo but can also occur in children who simply have a cold – if they are very resistant to having their nose wiped, crusts of mucus can accumulate, but they would typically be on top of intact skin and be easily wiped away.

Chickenpox presents with itchy vesicular lesions, but they do not tend to crust.

Cold sores, caused by herpes simplex infection, would be another differential. They tend to present with pain and a tingling sensation, often 1-2 days before anything is seen on the skin. The skin lesion is usually at the corner of the mouth, and the person may have felt generally unwell for a few days, for example with a fever or sore throat.

A child who has fallen and grazed their knee, and then scratched the graze, may have some fluid from where they have pulled the scab off, but again this wouldn’t be likely to give such a clear gold-brown appearance, and there should be a clear history of the initial injury.

Other possible differentials include fungal infection (although they do not usually cause such a significant crust) or burns/scalds. Don’t forget to consider safeguarding if a child has had a burn or scald - if in doubt, it would be sensible to suggest that the patient see their GP.

4. Ask if they have had this before

The Pharmacy First flowchart stipulates that you should exclude recurrent impetigo, specifically defined as two or more episodes in the previous year, before treating. It’s always worth checking whether any medical issue is new or recurrent, so while less frequent recurrence than this should not stop you treating, you might also want to suggest a GP review to explore potential underlying causes (such as any problem with the immune system, or an underlying skin condition such as eczema that isn’t well controlled).¹

5. Count all the lesions

If you have made the decision that this is impetigo, then the treatment options vary with number of lesions; the clinical pathway advises offering topical treatment for three or fewer lesions or clusters and oral antibiotics for four or more. Lesions continuous with each other or which seem obviously grouped closely together could reasonably be considered as one, although you will need to use some judgement here. Don’t forget to ask if there are any other lesions on parts of the body other than the ones that you have been shown. See the clinical pathway flowchart for full treatment details.

Image 2: Non-bullous impetigo – typical lesions on the face (Science Photo Library)

6. Always advise on treatment adherence

For localised non-bullous impetigo the first-line treatment is antiseptic hydrogen peroxide 1% cream. Give patients clear instructions for applying this; while fusidic acid cream can be used second-line if the antiseptic cream is ineffective it is important to reserve topical antibiotic use for when it’s really needed.³

For widespread non-bullous impetigo, the first line oral antibiotic is flucloxacillin, which must be taken four times a day. Patients sometimes misunderstand and think that they need to take it every six hours, including getting up at night, but it’s fine to take one dose first thing, one just before bed, and two more doses spread out during the day. Adherence might be improved by linking the doses to things which are done regularly (eg, take when brushing teeth) and carrying the tablets around during the day.

One study suggested that key barriers to adherence included worries about side-effects, and concerns about swallowing tablets.⁵ It might be sensible to give some pre-emptive advice about side-effects, for example that antibiotic associated diarrhoea is usually self-limiting and stops within a few days of the end of the antibiotic course.⁶ Vaginal thrush can also be associated with antibiotics and can be treated over the counter. ⁷

As usual, adults who are concerned about swallowing tablets should be signposted to online videos showing them techniques to make this easier.⁹ Liquid forms are usually significantly more expensive than tablets and so generally reserved for young children and those who have a medical reason why they cannot swallow tablets, rather than being given out just for preference

7. Don’t forget to safety-net and talk about hygiene

Some people will deteriorate, even when treated appropriately – patients should be advised to return if symptoms worsen rapidly or significantly or have not got better after the treatment course has finished. Worsening symptoms might be on the skin (eg, lesions growing or spreading), or they might be to do with systemic health, for example a person might develop a high temperature or feel dizzy. All patients should also be advised about good hygiene – they should try to avoid touching the lesion and should wash their hands regularly (see box 2).

Box 2: Advice on how to avoid spreading impetigo⁴

• Avoid touching patches of impetigo and stop other people touching them.
• Always wash hands with soap after accidentally touching the area and ask other people to do the same.
• Wash hands before and after putting cream or ointment on the impetigo.
• Don’t share towels or flannels until the infection has cleared. Always use a clean cloth each time to dry the affected area.
• Clothing and bedding should be washed and changed daily during the first few days of treatment. Towels, pillowcases, and sheets should be washed on the hottest available setting (at least 60˚C) with the addition of laundry bleach.
• Children with impetigo should be kept off school or nursery until affected areas have healed or 48 hours after starting antibiotic treatment.
• Continue with normal bathing and skin care routine but be careful to avoid contaminating creams or ointments - use a spoon to dispense these, to avoid fingers contaminating the pot or tube after touching the skin.

8. Consider the wider public health issues

If there is any suggestion of an outbreak at a school or nursery then it would be sensible to inform public health – you can find contact details for your local public health team online.⁹ Children with impetigo should stay off school until their sores have crusted and healed, or for 48 hours after they have started antibiotics;¹⁰ the same applies for adults and work, but those who handle food at work must specifically inform their employer,¹ who may have their own arrangements for when an employee can return.

Parents do not need to request a letter from their GP to cover time off school – schools are obliged to accept a note from the pupil’s parent or guardian.¹¹ If advising time off school, it would be worth proactively mentioning this, to stop a GP appointment being wasted with a request for a letter.

9. Think about any underlying diagnoses

As above, impetigo can occur in those who have eczema – if this appears to be the case, and the patient or their parent don’t seem clear about how to treat their eczema, then it may be worth signposting back to the GP for a review of its long-term management. Eczema is often sub-optimally managed, with not enough emollient being used; a GP review may help to improve the skin barrier by improving eczema management.

Chickenpox generally only needs symptomatic management, which could be bought over the counter, but if a child is unwell or has a fever then they should see the GP as complications of chickenpox can be severe.

Cold sores are often recurrent but generally need no more than over the counter management with topical aciclovir, which could be kept at home to be started early in the next attack, ideally as soon as the tingling sensation is felt. If there are wider concerns about recurrent infection and the immune system then the person should be signposted back to their GP.

Dr Toni Hazell is a GP in north London

This is the latest in a series of articles on aspects of Pharmacy First from The Pharmacist.