Trained in dentistry, Sree is currently pursuing lab sciences. She loves researching and sharing information on various health topics.
Impetigo: Beyond Skin Deep
Impetigo, also known as pyoderma or infantigo, is a debilitating skin disease that affects both children and adults. Not only does it mar the flesh, it also leaves deep emotional and psychological scars on those who are affected.
Unlike most skin diseases, the symptoms of impetigo are recurring. Thus, sufferers of this skin disorder are usually trapped in a frustrating cycle of remission and exacerbation. The worst thing about this skin disease is that it is highly contagious. Hence, affected individuals sometimes fear the social stigma more than the sleepless nights that comes with it.
But what is impetigo, really? What causes it? More importantly, how do you cure it? This article aims to hold your hand and walk you through the entire process, from determining how to avoid the disease to finding a way to live with it.
Learning More about Infantigo
Impetigo is categorized as a skin infection of bacterial origin. Impetigo appears as reddish blisters that erupt and ooze liquid. The liquid then forms a yellow-brownish or golden-brown or honey-colored crust. These blisters can be present anywhere on the surface of the body such as the arms and the legs. That said, they frequently appear on the affected person's face, particularly around the mouth and the nose.
There are several ways in which impetigo can spread. One is from one body part to another. If the affected individual scratches the infected area, the bacteria that cause impetigo will then embed themselves beneath the nails and spread to the person's fingers. If the person touches another part of his body, he then spreads the bacterial causative agent (and the disease) to that distal body part. This goes on and on until several parts of the person's body are infected.
One of the most common ways in which impetigo can be transmitted from person to person is through close contact. This can happen by touching an infected part of an affected individual's skin. Impetigo can also be transmitted through contact with the affected person's belongings such as clothes, bed linens, towels, clothing, and other personal articles.
Though impetigo can affect adults, it is more common in children, usually those between two to five years of age. In fact, it is considered as the most common bacterial dermal infection in kids in Canada, Northern Europe, and North America. In 2010, impetigo has affected more than 100 million individuals worldwide. One essential factor to consider here is the high communicability of this disease. Kids like to share stuff from food to toys. More than that, they experience direct physical contact with each other during playtime. They are rarely conscious about the consequences of not observing proper hygiene when they're having fun. This makes them highly susceptible to contracting the disease from their playmates, schoolmates, and friends.
In some instances, the blisters caused by impetigo turn into sores and gradually go away within a couple of weeks even without intervention. There are those that would say that impetigo is rarely serious but some medical professionals would beg to differ. After all, one must consider not just the physical effects of the disease but also its effects on the inflicted individual's self-esteem and social relationships.
Risk Factors Associated with Impetigo
Impetigo is commonly contracted by persons dwelling in confined spaces. That includes army barracks, dormitories, and orphanages. Warm, humid environments also facilitate the spread of the disease.
Individuals with compromised immune systems are more at risk of developing impetigo than others. Such persons include diabetics, cancer patients receiving chemotherapy or radiation therapy, patients with AIDS, people with auto-immune diseases, and those taking immunosuppressive drugs.
Patients with chronic respiratory conditions such as emphysema and cystic fibrosis are also more likely to develop pyoderma. The same goes with patients with severe kidney problems who undergo dialysis.
Moreover, individuals with dermatitis are more predisposed to developing impetigo than others.
Other groups of people who are prone to contracting impetigo are those who are frequently in and out of the hospital. That includes healthcare professionals. Despite great measures taken to sanitize the hospital environment, it is nearly impossible to eradicate the presence of the bacterial causative agent of this skin infection. This places the following types of patients at risk:
- The immunocompromised
- Burn patients
- Patients with surgical wounds
- Patients with invasive devices such as feeding tubes, urinary catheters, and intravascular catheters
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The presence of foreign objects in the body creates a bridge for the bacteria to pass from the outside world to your internal systems.
The Signs and Symptoms of Pyoderma
The initial signs of impetigo include an area of red skin that is itchy. They may multiply and grow bigger. They may range from the size of a pimple to a patch bigger than a quarter coin. After a while, the sores will erupt and begin oozing pus. The pus will then dry up resulting to the characteristic thick and honey-colored crust. Imagine moist granules of brown sugar that have clumped together. When the crusts disappear, they leave behind red marks. After treatment, these red marks can disappear leaving no scars at all.
Despite how it may look, the blisters caused by impetigo are not painful at all. However, they do cause a terrible itching that can keep a child or an adult awake all night. Nevertheless, the infected person must take care never to scratch or even touch the infected skin so as to lessen the risk of spreading it to other parts of his body. This, in itself, can be a pretty tough ordeal.
The Diagnosis of Impetigo
For an experienced medical professional, it's easy enough to diagnose impetigo just through visual inspection. As mentioned, its hallmark sign is the honey-colored crust. Other ways to visually confirm impetigo is to determine whether the changes in the patient's skin do not exceed a two palm surface and if the affected visible parts of the patient's body are less than five areas. When you see the doctor, expect him/her to ask about the development of the skin lesions. If it's impetigo, the progression is usually slow. In other words, impetigo has a pretty long incubation period.
There are also instances where the physician may request for a sample of the pus to be obtained. A healthcare provider will carefully wipe the crusted patch with a swab. In the laboratory, they will attempt to confirm the presence of the bacterial causative agent of the disease. As infantigo can be caused by one out of two possible species of bacteria, this lab exam can aid in determining which antibiotic must be prescribed. Moreover, impetigo tends to coexist with other skin infections. Thus, a swab will aid in determining the presence of other dermal infections like shingles or ringworm.
Obtaining a pus sample is not always necessary but the physician may order it in the following instances:
- If the symptoms are more severe than usual and has spread to various parts of the patient's body
- If the patient shows failure to respond to treatment
- If the impetigo is recurrent
In cases of recurrent impetigo, the physician may also order for a sample to be taken from the patient's nose. This way, he'll be able to know if the causative bacterial agent originates from there.
It's also possible for the doctor to order a urinalysis and blood tests if the presence of other types of infections are suspected. A blood test that's ordered in case of extensive impetigo may reveal neutrophilic leukocytosis. This pertains to an abnormally high level of neutrophil (a kind of white blood cell).
Three Types of Impetigo
1. Non-Bullous Impetigo
This is what medical professionals refer to as impetigo contagiosa. It is the more common type of impetigo. In fact, it makes up about 70% of all cases of impetigo.
This ordinarily begins as patches of red skin around the oral and nasal skin areas. The rashes show up 4-10 days after the person has been infected by the bacterial causative agent. Blisters form but they aren't always noticeable as they erupt quickly, leaving clusters of yellowish pus in their wake. They dry up to form the crusty surface that impetigo is known for. Imagine moist but crunchy cornflake crumbles. After these crusts fall off, the affected areas become hyperpigmented for up to six months or less. That said, the discoloration is thankfully only temporary.
Non-bullous impetigo is very itchy and complications usually result from skin injury due to the scratching of the infected blisters. Compared to the bullous type of pyoderma, the patches of non-bullous impetigo are small, usually about a centimeter or slightly bigger. Though they may not grow larger than that, it's not uncommon for satellite patches to form around an existing patch. From there, these newly formed patches will continue to multiply and spread outward.
The causative agent of non-bullous impetigo can be either the Staphylococcus aureus or the Streptococcus pyogenes. In the past, non-bullous impetigo was caused mainly by strep but nowadays, majority of the cases of impetigo are caused by a combination of these two bacteria. Staphylococcus aureus normally resides on the surface of the skin. Thus, it can easily make its way into the deeper layers of the skin through even the smallest openings such as minor cuts and mosquito bites. This happens particularly when they are scratched or left uncleansed. The incubation period for staphylococcal impetigo is four to ten days after exposure to the bacteria. Because of the long incubation period, it's possible for an affected individual to be contagious even when he hasn't yet shown any obvious sign or symptom of pyoderma.
It's possible for children to contract non-bullous impetigo from school, camp, or daycare. It's also not uncommon for adults who engage in contact sports like wrestling to contract this highly contagious skin disease. This is also true with athletes who share bathrooms, locker rooms, and sports equipment. You can even get impetigo from day spas. In fact, any activity that involves skin-to-skin contact can facilitate the transfer of impetigo from one person to another. What's more, you can acquire it from contaminated food prepared by handlers who have failed to wash their hands. The thing about food contaminated with strep or staph is that they taste quite normal so you don't get any warning sign at all. Once the staph has successfully entered the bloodstream, this could lead to a fatal complication known as sepsis.
Two of the most severe complications of non-bullous impetigo are cellulitis and post-streptococcal glomerulonephritis. The latter occurs when the causative agent of the skin infection is the Streptococcus pyogenes.
Non-bullous impetigo is not just transmitted through direct contact but also via nasal carriers. The latter is true particularly with impetigo caused by the strep. This means that when your skin is not intact and then it is exposed to streptococci bacteria in the air, it's possible for you to develop impetigo. It's also possible for the impetigo to spread when one person scratches his nose and then touches his own skin or other people's compromised skin. While it was mentioned here that impetigo usually goes away on its own, it's also possible to keep re-infecting healing patches of skin by re-introducing the bacteria to them.
Note that the nose itself may not be infected but instead serves as a carrier for the bacteria. One sure way to determine whether the impetigo was caused by nasal carriers is through taking nasal swabs. In a household, for instance, if any one of the family members is identified as a positive carrier, all immediate family members will be advised to apply Naseptin or any other antibacterial cream into their inner nostrils. This is done for a week or so to stop the spread of the infection. After the treatment, re-swabbing of the nostrils may be requested.
The incubation period for streptococcal impetigo is one to three days after exposure to the bacteria.
2. Bullous Impetigo
This less common type of impetigo typically occurs in infants and babies younger than two years. Unlike its more popular sister, bullous impetigo does not start off on the face but begins in the extremities and sometimes all over the torso. They may also break out on an infant's bottom and be mistaken for diaper rash. They can also show up in skin folds such as the axilla, the groin, and the neck.
The blisters or bullae are medium to large (5mm or more) in size and are surrounded by red skin. They spread quickly. The skin on top of the blisters are very flimsy and can fall off easily. When they peel off, they expose big, red, and raw patches beneath.
The skin disease manifests itself as pus-filled blisters which erupt after a few days. Like impetigo contagiosa, a yellowish crust is left on the skin. After they heal up, no scarring or discoloration occurs. It causes itching but not pain. However, the child may experience fever and swelling of the glands. Some infants and toddlers also suffer from diarrhea. Considering the age of the patient, prompt medical care is required.
The causative agent of bullous impetigo is a specific strain of Staphylococcus aureus. This type of staph discharges a unique toxin (exfoliative toxin A) which attacks the skin layer. This bacteria reduces the adhesion of the cells and thus, weakens the skin. When the bullous impetigo is severe, this results to the separation of the epidermis (the external layer of the skin) from the dermis (the inner layer of the skin). This complication is known as SSSS or staphylococcal scalded skin syndrome. It is characterized by widespread areas of peeling. Usually, there is flaking and cracking on the skin around the mouth. When the outer layer of the skin comes off, it exposes raw and red skin that looks not too different from burns. SSSS typically affects kids below six years of age but may also occur in adults especially those who are immunocompromised or are suffering from renal failure.
Bullous infantigo tends to coexist with another skin disease such as eczema. One of the most severe effects of chronic bullous impetigo is kidney disease. The mortality rate for infants and children is 3% or less while the mortality rate for adults is a whopping 60%.
But how do babies get this kind of skin disease? One possibility is that the bullous impetigo may be a nosocomial (hospital-acquired) infection passed from the healthcare provider to the newborn. As mentioned, Staphylococcus aureus is a normal resident of the human skin. Thus, infection may occur as a result of poor hygiene rendered by the child's caregiver. It is also important to note that the immune systems of newborns are not yet fully developed and this makes them more susceptible to contracting pyoderma.
After 48 hours of being cured by antibiotic treatment, the bullous impetigo can safely be declared as non-contagious.
Ecthyma is yet another rare type of impetigo. This is more severe than the two previous types as it penetrates deeper into the tissue. It is sometimes referred to as ulcerative pyoderma. As the name suggests, this type of impetigo causes ulcer formation or deep level skin erosions extending to the dermis.
This type of impetigo usually affects the lower extremities particularly the legs, the thighs, the feet, and the ankles. They may also break out on the buttocks. Apart from the lesions, other symptoms include swollen and painful lymph nodes.
The lesions associated with ecthyma start off as vesicles. These are small blisters such as those seen in chickenpox. These blisters grow in inflamed parts of the skin. After a while, you'll notice a hardened crust covering the blister. The crusts are thick and difficult to scrape off. But once they are removed, an indurated ulcer will be exposed. The ulcer will appear reddish and inflamed. It usually exudes pus.
The lesions related to ecthyma are not expected to grow any bigger than a diameter of 0.5cm to 3cm. Like the first two types of impetigo, it's possible for ecthyma to go away on its own. However, unlike the first two, this type of impetigo leaves permanent scars. Apart from the scarring, the most severe complications associated with ecthyma are cellulitis, gangrene, erysipelas, and bacteremia. One rare complication is post-streptococcal glomerulonephritis.
The causative agent of ecthyma is the group A beta-hemolytic streptococci. However, this may also be caused by a staph.
Who is at risk for developing this severe form of impetigo?
Ecthyma may affect people of all ages and sexes. Even so, kids, the elderly, and immunocompromised individuals are the ones most at risk for contracting this skin infection. The latter includes patients suffering from any type of malignancy, HIV, or neutropenia. Other risk factors include poor hygiene, dwelling in crowded spaces, and high humidity and temperature particularly in tropical environments. The presence of existing skin injuries and diseases (ex. insect stings, dermatitis) can also predispose a person to develop ecthyma.
When left untreated, non-bullous and bullous impetigo may worsen and become ecthyma. This is true especially in impetigo patients who fail to observe good hygiene.
To form a positive diagnosis of ecthyma, the doctor may order skin biopsy besides physical examination. That is, a tiny amount of the skin will be obtained from the patient to be studied in the laboratory. Oftentimes though, collecting the fluid from the blister to be examined in the lab is enough.
Causes of Impetigo
Streptococci, staphylococci, what's the difference? Both are able to cause impetigo. Both are round as the name (cocci) suggests. Another similarity is that they are both Gram-positive microbes. This means that they yield positive results in the Gram stain test. Both strep and staph are non-motile and non-sporing anaerobic bacteria. This means that they do not thrive where oxygen is present. The fact that they are non-sporing means that they are pathogenic or that they have the ability to cause disease. Non-motile bacteria are unable to move towards more optimal environments to guarantee their survival. That is, they lack the ability to move away from inhospitable areas towards areas rich in nutrients. This means that impetigo caused by strep and staph are definitely treatable. To spot the main differences between these two causative agents of impetigo, view the table below.
A chain consisting of round cells
Manner of Division
They divide in multiple axes or several different directions.
They divide in a single axis. That is, they divide in one linear direction.
This means that strep requires enriched media whereas staph does not.
The human skin
The human respiratory tract
Alpha/ Beta/ Gamma hemolysis
This means that strep destroys red blood cells.
Most types out of 40 species do not usually cause diseases.
Most types out of 50 species tend to cause disease.
Impetigo, skin diseases, infection of wounds and surgical sites, cellulitis, conjunctivitis, meningitis, food poisoning, and toxic shock syndrome
Impetigo, cellulitis, necrotizing fasciitis, infections in the blood, meningitis in infants, strep throat, pneumonia, scarlet fever, and toxic shock syndrome
These causative agents start off by colonizing intact and healthy skin. Then, like true opportunists, they wait for the skin to lose its integrity. In case the skin sustains a break such as from a cut or an animal bite, that's when the staph or the strep is inoculated into the wound and does its damage. The infantigo that results is known as primary impetigo. If the skin's integrity is already compromised by an existing skin condition such as lice infestation or eczema, the kind of impetigo that develops is considered as secondary impetigo. This is why good hygiene is essential in the prevention of the disease.
Streptococcus pyogenes is derived from the Greek word pyo which translates to pus and genes which means forming. This makes sense because the infections caused by this bacteria, like impetigo, generates pus. Strepto means chain and coccus translates to berries. That's because the cells of streptococci are connected together in chains of round berry-like cells.
The thing about staphylococcus bacteria is that they have the ability to survive temperature extremes, dehydration, and even exposure to high amounts of salt.
When should you seek medical advice?
You are advised to seek medical care immediately upon suspecting that you have caught or developed impetigo. Though this skin disease may go away on its own, it is essential to obtain treatment to eliminate the cause and thus, prevent re-infection of your own skin as well as transmitting the infection to others. Moreover, having a professional look at your skin will ensure proper diagnosis as other more severe skin conditions like cellulitis may be mistaken for impetigo.
Prior to your appointment with your doctor, prepare the following data:
- A list of symptoms that you (or your child) are experiencing
- A list of the drugs and supplements that you (or your kid) have been taking
- Any existing medical conditions or skin conditions
Likewise, when seeking treatment, do not neglect to ask the healthcare professional these important questions:
- What are the possible causes of the impetigo?
- What tests are required to make a final diagnosis?
- What measures should you take to aid in treating the infection and halting its spread?
- What skin care routines should you follow while waiting for the blemishes to heal up?
Prepare to be asked pertinent questions by the physician such as:
- When the sores began to show up
- The appearance of the sores when they first showed up
- The presence of breaks, cuts, wounds, or insect bites on the affected site prior to infection
- Whether pain or itching is present
- Factors that cause the sores to worsen
- If someone else in your school or household has impetigo
- If you've had the same concern in the past
To prevent the spread of impetigo to other patients, call your physician's clinic first to schedule your appointment. Ask whether there are any measures that you must observe to prevent passing the infection to others in the reception area.
How to Treat Impetigo
Unfortunately, there is still no known prophylactic treatment or vaccine for pyoderma. Prevention and early detection and treatment still play a huge role in the eradication of the infection. While impetigo may go away in two to three weeks' time, treatment is still recommended as it can cut down your almost month-long suffering to one week. The primary focus of the treatment of impetigo is the management of symptoms while keeping the complications at bay.
Depending on the type and the severity of your impetigo, your physician may prescribe an antibiotic in topical or oral form. If the affected areas are small and few and the impetigo has not penetrated into the dermis, an antibiotic cream or ointment such as mupirocin may suffice. Apply the antibiotic ointment only to affected areas of the skin and exactly as prescribed by the physician.
Usually, these creams are applied thrice or four times daily for a whole week or more. Prior to application, make sure that you wash the affected area gently with soap and water. Remove as much dried up crusts as you can without breaking the skin any further. Apply the cream and then wash your hands thoroughly afterwards. When applying the cream to another person (such as an infant or your child), you can make use of sterile latex gloves. Antibiotic creams to treat impetigo are not without side-effects. Some of these unpleasant effects are irritation and redness of the skin and itching on skin patches where the cream was applied. Usually, these side-effects are tolerable. After seven days of using the topical antibiotic with zero to minimal improvement, contact your physician to explore other treatment options.
If the infantigo proves to be more extensive, then antibiotic pills may be ordered. Antibiotic pills are usually taken twice to four times daily for seven to ten days. Side-effects of oral antibiotics include nausea, vomiting, and diarrhea. Inform your physician immediately after observing these symptoms so that s/he can check whether these are just normal side-effects or if you're allergic to the drug.
Whether you've been asked to take oral antibiotics or topical antibiotics, you'll have to follow the whole course of the treatment to stop the infection from coming back. In other words, don't stop taking or applying your meds just because you've experienced some relief. Otherwise, the bacteria will develop resistance to the drug and you and your physician will have a hard time treating the disease the second time around. As it is, the number of impetigo cases caused by antibiotic-resistant bacteria are continuously increasing.
What if Your Impetigo has Progressed to Ecthyma?
First, it is necessary to treat any existing skin condition that occurs along with the impetigo. A topical antibiotic such as fusidic acid may be prescribed if the ecthyma is localized. That said, a topical cream may be unable to penetrate the deeper layers of the blisters. In some cases, the crusted areas are soaked with a sterile compress for about ten minutes and then gently wiped off. After the crusts have been removed, the ointment or any other antiseptic such as povidone iodine may be applied. This process is to be continued for several days even after the blisters have healed.
More often, oral antibiotics are recommended for cases of ecthyma particularly when the patient shows poor or slow response to antibiotic creams or ointments. The oral antibiotic of choice is a penicillin such as flucloxacillin. Penicillin is effective in combating both streptococcal and staphylococcal impetigo. The treatment of ecthyma may take weeks.
What if the causative bacterial agent is resistant to penicillin?
The thing about staph bacteria is that they're very adaptable. Before, staph infections can easily be combated through the use of penicillin. However, by the 1950's, many infections have proven to be resistant to penicillin. And today, only 10% of staph infections can be treated with it. In the 60's, methicillin was discovered and used to treat infections caused by bacteria that are resistant to penicillin. Yet, in the recent years, more and more infections have shown to be invulnerable not just to penicillin but also to methicillin.
The highly evolved microorganisms which cause these infections are referred to as methicillin resistant staphylococcus aureus or MRSA, otherwise known as the "super bug". This has a lot to do with the excessive use and abuse of antibiotics by people today. Physicians may be partly to blame for prescribing powerful antibiotics just to treat a patient's snotty nose. While strains of MRSA may not be more virulent than strains that are still resistant to methicillin or penicillin, they are more difficult to treat.
MRSA is usually found on the skin, in the throat, and inside the nostrils. This means that it's possible for you to be carrying colonies of MRSA without manifesting any signs or symptoms for several weeks to several years. Even so, MRSA has the potential to cause skin infections such as impetigo and boils any time your integumentary system or your immune system are compromised.
One thing you need to know about staphylococcus is that as long as it remains on the skin, it can only cause mild to moderate infection. That said, once it enters through the break in your skin, invades your bloodstream, and comes into contact with your internal organs, it can cause more severe systemic infections. For instance, if the staph finds its way to your heart though a heart valve or a pacemaker, the infection can start there. If the bacteria finds its way to your bone through a replacement joint, the infection may start there. The first symptoms would be observed as high temperature, generalized fatigue, and pain or swelling in the affected area.
There are many ways in which you may be colonized with MRSA. One is through skin-to-skin contact (contact sports, an ordinary handshake, etc.) and the other is through contact with contaminated surfaces (countertops, doorknobs, phones, etc.) Risk factors that can increase a person's susceptibility to developing MRSA-related impetigo includes the recent use of antibiotics, prolonged hospitalization, weakened immune system, and prolonged exposure to individuals who are colonized with MRSA. The latter may consist of hospital patients or healthcare workers. Before, MRSA was more prevalent in hospital environments, taking advantage of individuals with IV lines, postoperative clients, and the chronically ill. Studies in the past also revealed that patients undergoing hemodialysis are more susceptible to acquiring MRSA than any other type of patients in the hospital.
However, today, MRSA has found its new home outside the hospital setting. By 2006, 50% of skin diseases caused by MRSA are found in the community, infecting healthy individuals. It infects persons with burn injuries and cuts. You may get it when you get a tattoo or pierce your bellybutton or when you cut yourself while shaving. You can get it when you hug an infected person or borrow another someone else's sports pads. You can get it just from touching or being touched by a person with an open sore. As with impetigo caused by MSSA (methicillin susceptible staphylococcus aureus), impetigo caused by MRSA is spread easily in confined living quarters such as in the military or in prison. Thus, skin infections caused by MRSA have earned their name as the new impetigo.
Diagnosis of MRSA takes 2 to 3 days after analysis of the culture. If involvement of other parts of the body are suspected (such as the bones, the heart, and the lungs) then a CT scan, an echocardiogram, an x-ray, or a series of blood tests may be ordered.
Treatment of infantigo caused by MRSA involves the use or alternative antibiotics such as vancomycin. Your doctor may ask you to stay at home for ten days while taking antibiotics such as clindamycin, doxycycline, or trimetophrim-sulfamethoxazole. The downside of this alternate treatment route is that such drugs are usually accompanied by more side effects.
Erythromycin is another drug which is still used in the treatment of impetigo. However, it is useless in cases where the skin infection is caused by strains of erythromycin-resistant Staphylococcus aureus and Streptococcus pyogenes.
In case the antibiotic treatment does not work, you'll have to be admitted to the hospital. Once admitted to the hospital, you will be treated with medication introduced via the IV route. The antibiotic treatment will continue after your discharge from the facility. This can be in the form of continuous IV or oral antibacterials given for up to two months. The IV meds can be administered in an outpatient department or by a visiting nurse at the comfort of your own home.
Extra measures will also be taken at the hospital to prevent the spread of impetigo caused by MRSA. This includes the application of mupirocin ointment or was