Who to refer

The PGDs for impetigo list specific inclusion and exclusion criteria. Most patients with suspected impetigo will not be systemically unwell but parents/guardians may be concerned about their child’s appearance. 

A few patients may have symptoms suggesting more severe illness (e.g. painful, hot, swollen skin, and spreading redness) or who are at risk of severe illness (e.g. immunosuppressed individuals). 

Some patients may seek assessment by a pharmacist, but do not meet the criteria for the PGD under which the service is operating (e.g. people with recurrent or bullous impetigo). It is important to recognise severely ill patients and ensure they get urgent care.

Pharmacists are not expected to diagnose unusual conditions but to recognise those that do not fit the picture for non-bullous impetigo and refer appropriately.

Red flags

Complications with impetigo are uncommon. The PGDs and corresponding Pharmacy First clinical pathway list conditions for urgent referral of patients with suspected impetigo. Call 999 or send to A&E if sepsis is suspected.

Management options

Antibacterials are recommended for impetigo to shorten the course of illness and reduce the chances of it spreading to other sites/people: 

• Topical treatment with a five-day course of hydrogen peroxide 1% cream is first-line treatment for localised non-bullous impetigo 
• Fusidic acid cream can be offered second-line if hydrogen peroxide is unsuitable (e.g. if impetigo is around the eyes) or if it has been ineffective and the impetigo remains localised
• A five-day course of oral flucloxacillin is first-line for widespread non-bullous impetigo
• Second-line treatments are listed in the clinical pathway. If flucloxacillin is indicated, check for penicillin allergy and supply alternative (clarithromycin or erythromycin are subject to inclusion/exclusion criteria) if necessary.