Impetigo

Key Points

• Impetigo is a contagious superficial bacterial skin infection, most common in children ages 2 to 5 years.
• Core patterns are nonbullous, bullous, and deeper ecthyma lesions.
• Common organisms include Staphylococcus aureus, Group A beta-hemolytic Streptococcus, and selected MRSA contexts.
• Nursing priorities are infection-containment hygiene, lesion care, antibiotic adherence, and complication surveillance.

Pathophysiology

Impetigo develops when bacteria invade superficial skin layers. Primary impetigo occurs through direct invasion of intact skin, while secondary impetigo occurs at sites of prior barrier disruption such as bites, scratching, or trauma.

Once bacteria proliferate, local inflammation and exudative lesions form and can spread through self-contamination. Risk increases in hot humid climates, crowded living settings, daycare exposure, poor hygiene or nutrition, immunosuppression, and preexisting skin breakdown.

Classification

• Nonbullous impetigo: Vesicle or pustule ruptures and forms honey-colored crust on an erythematous base, often on face/extremities.
• Bullous impetigo: Small vesicles enlarge into bullae with clear to yellow fluid that may become purulent or dark; lesions commonly involve skin folds, axilla, and sometimes oral mucosa.
• Ecthyma: Deeper bullous-impetigo subset with deeper lesions and crusts that may appear honey, brown, or black, often with purulent exudate.

Nursing Assessment

NCLEX Focus

Identify lesion pattern and spread risk first, then determine whether findings suggest localized disease versus complication progression.

• Document lesion type, location, exudate, crust characteristics, and spread pattern.
• Differentiate nonbullous versus bullous findings and screen for ecthyma depth cues.
• Assess for secondary-trigger pattern in nonbullous disease (for example recent skin trauma or preexisting dermatitis such as atopic dermatitis).
• Assess for fever and regional lymph-node enlargement in nonbullous presentations.
• Assess transmission risk from scratching, long fingernails, and household/daycare contact patterns.
• Evaluate risk context: young age, immunosuppression, nutrition and hygiene barriers, and recent skin trauma.
• Monitor for complication cues such as worsening systemic illness, scarring progression, and severe skin involvement.
• In suspected GABHS-related cases, assess renal-risk indicators and kidney-function trend because of poststreptococcal glomerulonephritis risk.

Diagnostics

• Diagnosis is usually clinical from lesion morphology and distribution.
• Obtain lesion culture to identify causative bacteria when confirmation is needed.
• Consider skin biopsy when the condition is treatment-refractory.

Nursing Interventions

• Administer prescribed antibiotics and monitor response trend.
• Clean crusted lesions with soap and water before topical antibiotic application to improve medication contact.
• Use systemic antibiotics for bullous impetigo, ecthyma, or widespread nonbullous disease per order.
• In recurrent disease with nasal colonization, support prescribed nasal mupirocin workflow.
• Keep fingernails trimmed, discourage touching/scratching, and cover open lesions to reduce spread.
• Reinforce strict hand hygiene and disinfection of items that contact lesions.
• Teach temporary exclusion from close child-contact settings during active contagion; return to school/daycare is typically after 1 to 2 days of antibiotic therapy per policy.
• Reinforce completion of the full antibiotic course to reduce recurrence and resistance risk.

Complication Risk

Delayed treatment or poor infection-control adherence can increase risk of spread, deeper lesions, renal sequelae, or systemic infection.

Pharmacology

Drug Class	Examples	Key Nursing Considerations
antibiotics	Topical and systemic regimens	Route depends on disease extent and lesion type; monitor clinical response and adherence.
topical-antibiotic-therapy	Mupirocin contexts	Useful for selected topical lesion care and recurrent nasal-colonization protocols when ordered.

Clinical Judgment Application

Clinical Scenario

A 3-year-old in daycare presents with multiple crusted facial lesions and mild fever; caregiver reports frequent scratching and shared towels at home.

• Recognize Cues: Honey-crusted lesions, fever, contact-spread risk factors.
• Analyze Cues: Pattern is most consistent with nonbullous impetigo with high self-contamination risk.
• Prioritize Hypotheses: Immediate priorities are infection containment, skin protection, and timely antibiotic treatment.
• Generate Solutions: Start lesion-care hygiene bundle, administer ordered antibiotics, and educate caregiver on home precautions.
• Take Action: Clean crusts before topical application, trim nails, cover lesions, and reinforce hand/item hygiene.
• Evaluate Outcomes: Lesions improve without new spread, fever resolves, and caregiver demonstrates correct prevention steps.

Related Concepts

• infectious-and-inflammatory-skin-conditions - Category-level skin infection pattern recognition and escalation.
• impaired-skin-and-tissue-integrity - Barrier disruption and healing-risk assessment context.
• glomerulonephritis - Potential poststreptococcal renal complication pathway.
• hand-hygiene - Core transmission-prevention intervention.
• multidrug-resistant-organisms - MRSA risk context for antimicrobial planning.

Self-Check

1. Which findings best distinguish nonbullous from bullous impetigo?
2. Why is crust removal important before topical antibiotic application?
3. Which cues should prompt assessment for poststreptococcal renal complications?