Prescribers should consider hydrogen peroxide 1% cream for people with localised non-bullous impetigo who are not systemically unwell or at high risk of complications, according to NICE. The cream should be applied two or three times daily for 5 days.
The guidance says hydrogen peroxide 1% is as effective as a topical antibiotic, has a low risk of adverse events, and supports good antimicrobial stewardship.
NICE found no evidence to support the use of any other topical antiseptics to treat the condition.
NICE says antibiotics should only be used for localised non-bullous infection if hydrogen peroxide cream is unsuitable (eg, if infection is near the eyes) or ineffective.
For people with widespread non-bullous impetigo who are not systemically unwell or at high risk of complications, a short course of a topical or oral antibiotic should be offered. Fusidic acid 2% is the first-choice topical antibiotic; alternatively, mupirocin 2% can be prescribed if resistance to fusidic acid is suspected. Both are applied three times daily for 5 days. Repeated doses or extended use of the same topical antibiotic should be avoided.
For patients with bullous infection and those who are systemically unwell or at high risk of complications (such as those who are immunocompromised or have co-existing skin conditions), oral antibiotics are recommended. The first choice is flucloxacillin, given at a dose of 500mg four times daily for 5 days in adults. If there is penicillin allergy or flucloxacillin is otherwise unsuitable, alternatives are clarithromycin or (in pregnancy) erythromycin.
Topical and oral antibiotics should not be combined. NICE says there is no evidence to suggest that prescribing both is more effective than a topical treatment alone.
The new treatment recommendations are summarised in the MIMS table of antibiotic regimens.