Which decision rule is used for impetigo?

Topical or oral?: Widespread lesions; Bullous impetigo; Systemically unwell; High risk of complications

What should I prescribe for impetigo?

Hydrogen peroxide 1% cream (localised, not unwell): Apply two or three times a day (5 days); Fusidic acid 2% cream (if peroxide unsuitable): Apply three times a day (5 days); Widespread / bullous / unwell: flucloxacillin: 500 mg four times a day (5 days (children per BNFc)); Penicillin allergy: clarithromycin: 250–500 mg twice a day (5 days)

Impetigo: Hydrogen Peroxide, Fusidic Acid & Exclusion | Urgent Care Clinic

Q: What are the red flags for impetigo in urgent care?

Systemically unwell, widespread bullous lesions → Admit / specialist; Recurrent impetigo → Swab; consider nasal carriage, PVL; Underlying eczema with punched-out painful lesions → Eczema herpeticum — same-day dermatology/admission; Infant with blistering and unwell → Staphylococcal scalded skin — admit

Q: What safety-netting advice should I give for impetigo?

Return or seek help if: Spreading despite treatment after 5 days; Fever, painful blisters, feeling unwell; Punched-out painful sores on eczema.

1Rule out first — red flags

If you find…	…then
Systemically unwell, widespread bullous lesions	Admit / specialist
Recurrent impetigo	Swab; consider nasal carriage, PVL
Underlying eczema with punched-out painful lesions	Eczema herpeticum — same-day dermatology/admission
Infant with blistering and unwell	Staphylococcal scalded skin — admit

2What to ask

Onset, spread, itch
Contacts, school/nursery
Eczema, scabies, insect bites (portal)
Recent antibiotics; allergies

3What to examine

Golden crusts (non-bullous) or flaccid blisters (bullous)
Extent: localised vs widespread
Obs if bullous/widespread

4How to do it — the senior at your shoulder

Why peroxide first?

NICE recommends hydrogen peroxide 1% cream first to reduce resistance to topical antibiotics like fusidic acid, which is now common.

Bullous vs non-bullous

Non-bullous: honey-coloured crusts around the mouth/nose. Bullous: fragile blisters that burst, leaving a collarette, more often in infants.

5Decide — investigate only if it changes the plan

Topical or oral?

Widespread lesions
Bullous impetigo
Systemically unwell
High risk of complications

Any present: Oral antibiotic (flucloxacillin). None present: Topical: hydrogen peroxide 1% cream.

Investigation	Only if…
Skin swab	Recurrent or not responding

6Treat & send home

Management & advice

Wash off crusts gently; good hand hygiene; don’t share towels
Exclude from school/nursery/work until lesions crusted and healed, or 48 h after starting antibiotics
Treat underlying eczema

Refer / follow-up

Eczema herpeticum, SSSS, systemically unwell → same day

℞

Discharge prescription (TTO)Typical adult doses. Check allergies, renal function, pregnancy/breastfeeding and interactions. Tap BNF ↗ to confirm.

Drug	Dose	Duration / notes
Hydrogen peroxide 1% cream (localised, not unwell) BNF ↗	Apply two or three times a day	5 days
Fusidic acid 2% cream (if peroxide unsuitable) BNF ↗	Apply three times a day	5 days
Widespread / bullous / unwell: flucloxacillin BNF ↗	500 mg four times a day	5 days (children per BNFc)
Penicillin allergy: clarithromycin BNF ↗	250–500 mg twice a day	5 days

7Safety-net

Say it like this

This is impetigo, a common skin infection. Use the cream for 5 days and wash off the crusts gently. It’s catching, so keep towels separate and stay off school or work until the spots have crusted over, or 2 days after starting antibiotics. Come back if it keeps spreading or you feel unwell.

Come back / call 111 — or 999 if severe — if:

Spreading despite treatment after 5 days
Fever, painful blisters, feeling unwell
Punched-out painful sores on eczema

8Patient leaflets — scan & go

Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.

Impetigonhs.uk/conditions/impetigo

9Where juniors slip up

Fusidic acid first line / repeatedly
Missing eczema herpeticum
No exclusion advice

▶Practise the decision

Revision practice. Work through a real or imagined case to rehearse the reasoning. It builds a model note to learn from. It doesn’t replace your judgement, your seniors or local guidance.

✎Blank clinic note template

Impetigo — clinic note

URGENT CARE — IMPETIGO PRESENTING COMPLAINT: HISTORY Onset, spread, itch: Contacts, school/nursery: Eczema, scabies, insect bites (portal): Recent antibiotics; allergies: RED FLAGS (record present / absent) [ ] Systemically unwell, widespread bullous lesions [ ] Recurrent impetigo [ ] Underlying eczema with punched-out painful lesions [ ] Infant with blistering and unwell PMH: DRUG HISTORY: ALLERGIES: SOCIAL (job / who is at home / driving): OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 ) EXAMINATION Golden crusts (non-bullous) or flaccid blisters (bullous): Extent: localised vs widespread: Obs if bullous/widespread: DECISION RULE — Topical or oral?: result ______ INVESTIGATIONS: none required / Skin swab — result: IMPRESSION: PLAN Treatment / TTO (drug, dose, duration): Advice given: Leaflet given (QR / printed): Impetigo Follow-up / referral: SAFETY-NETTING (told to return / call 111 / 999 if): - Spreading despite treatment after 5 days - Fever, painful blisters, feeling unwell - Punched-out painful sores on eczema Patient understands and agrees with the plan: Y / N Seen by: Grade: Date/Time:

✓Guidelines

NICE NG153 — Impetigo: antimicrobial prescribing

Doses are typical doses drawn from the guidance above. Always confirm in the current BNF/BNFc and your local antimicrobial policy.

More wounds, burns & skin

Lacerations & wound careClose it right, check tetanus, and know which wounds aren’t yours.Minor burns & scaldsCool, cover, size it — and know when it goes to the burns unit.Human & animal bitesWho gets prophylaxis, rabies risk and the fight bite.Insect bites, stings & tick bitesBig local reactions vs infection vs anaphylaxis — and Lyme.