Disclaimer: This guide is for informational purposes only. By providing the information contained herein we are not diagnosing, treating, curing, mitigating, or preventing any type of disease or medical condition. Before beginning any type of natural, integrative or conventional treatment regimen, it is advisable to seek the advice of a licensed healthcare professional. May contain affiliate links. Product photos/descriptions provided by company websites. This is not medical advice.

What causes it?

According to the National Institutes of Health, “Impetigo (im-peh-TIE-go) is a common infection of the superficial layers of the epidermis [skin] that is highly contagious and most commonly caused by gram-positive bacteria. It most commonly presents as erythematous plaques [red, elevated, solid, superficial lesions] with a yellow crust and may be itchy or painful. The lesions are highly contagious and spread easily. The infection may be bullous [elevated, fluid-filled blisters] or nonbullous [not fluid-filled]. The infection typically affects the face but can also occur in any other part of the body that has an abrasion, laceration, insect bite or other trauma.”

Nonbullous Impetigo is most commonly caused by S aureus which is responsible for 80% of cases. Group A beta-hemolytic Strep (GABHS) accounts for 10% of cases and the causative agent is a combination of S. aureus and GABHS 10% of the time. Methicillin-resistant S aureus (MRSA) has become more prevalent, especially in hospitalized patients. Today, community-acquired MRSA is rapidly increasing. The condition is more common in populations living in close quarters, daycare centers and prisons.1

Trauma, cuts, insect bites, surgery, atopic dermatitis, burns, and varicella are common mechanisms of skin breakdown. Once a lesion is present, self-inoculation [when a person transfers a disease from one part of their body to another] to other sites is very common. Malnutrition, immunosuppression, daycare attendance, overcrowding, diabetes, and poor hygiene make one more susceptible to impetigo.1

Streptococcal impetigo is most commonly spread through direct contact with other people with impetigo, including through contact with drainage from impetigo lesions. Lesions can be spread (by fingers and clothing) to other parts of the body. People with impetigo are much more likely to transmit the bacteria than asymptomatic carriers. Crowding, such as found in schools and daycare centers, increases the risk of disease spread from person to person.3

The incubation period of impetigo, from colonization of the skin to development of the characteristic lesions, is about 10 days. It is important to note not everyone who becomes colonized will go on to develop impetigo.3

Bullous Impetigo is caused almost exclusively by S aureus. Sometimes a deep ulcerated infection may occur known as ecthyma [crusted sores beneath the skin which ulcers form], which is a complication of bullous impetigo.1

Impetigo is more common in areas with hot, humid summers and mild winters (subtropics), or wet and dry seasons (tropics), but it can occur anywhere.2

It must be noted that impetigo is also a listed adverse reaction to the varicella (chickenpox) vaccine which can shed up to six weeks from a recently vaccinated person per the manufacturer.

What are the symptoms?

Nonbullous impetigo often starts as a vesicle or a pustule. Multiple vesicles often grow together into a single mass and rupture after which the pus fluid comes out and forms the characteristic honey-colored crust. Skin redness is also present.  There are often multiple lesions on the face and extremities, especially in areas in which disruption of the skin barrier has occurred.  The rapid spread and satellite lesion formation follow self-inoculation, often in areas with no apparent break in the skin barrier. Mild regional lymphadenopathy (swollen lymph nodes) is a common associated finding. Systemic symptoms such as fever are typically absent in nonbullous impetigo.1

Bullous impetigo begins with small vesicles that become flaccid bullae (fluid-filled sacs). The exfoliative toxin A produced by S. aureus causes loss of cell adhesion in the skin. The bullae contain a clear or yellow fluid which eventually progresses to become purulent or dark. Surrounding redness and swelling are typically absent.  Once the bullae rupture, a red base with a rim of scale remains. Bullous impetigo does not form a honey-colored crust. Lesions most commonly form in the intertriginous (where two skin areas may touch or rub together) regions and on the trunk and, unlike nonbullous impetigo, may occur in the buccal (mouth/cheek) membranes.  There are typically fewer lesions present than in non-bullous impetigo.  Regional lymphadenopathy (swollen lymph nodes) is absent. Systemic symptoms, such as fever, are more common than in nonbullous impetigo.1

Bullous impetigo is most prevalent in children aged 2-5 years old but can occur at any age. It is more common in infants.  Children younger than two account for 90% of cases of bullous impetigo.1

Ecthyma is a deep tissue form of impetigo. Ulcerative lesions penetrate through the epidermis and deep into the dermis.  These ulcers appear as “punched out” lesions with violaceous (bluish purple) margins. The crusts can be honey-colored or brown-black. The lesions may be purulent (pus-producing).1

Prevention

Appropriate personal hygiene and frequent body and hair washing with soap and clean, running water is important to help prevent impetigo. You should wash the clothes, linens, and towels of anyone who has impetigo every day. These items should not be shared with anyone else. The best way to keep from getting or spreading group A strep bacteria is to wash your hands often. This is especially important after coughing or sneezing.2

Children with impetigo should maintain good personal hygiene and avoid other children during the active outbreak. It is important to wash hands, linens, clothes and affected areas that may have come into contact with infected fluids. Sores can be covered with a bandage to help prevent spread by contact. If impetigo is recurrent, evaluation for the carriage of the causative bacteria should be performed.  The nose is a common reservoir.1 For colonization treatment options, see the Treatment section.

For general prevention, it is important to understand that, according to the NIH, many healthy people normally have staph on their skin, in their noses, or other body areas. Most of the time, the germ does not cause an infection or symptoms. This is called being colonized with staph. Most staph germs are spread by skin-to-skin contact. They can also be spread when you touch something that has the staph germ on it, such as clothing or a towel. Staph germs can then enter a break in the skin, such as cuts, scratches, or pimples.6

You are more likely to get a staph infection if you:

  • Have an open cut or sore
  • Inject medicines or illegal drugs
  • Have a medical tube such as urinary catheter or feeding tube
  • Have a medical device inside your body such as an artificial joint
  • Have a weakened immune system or ongoing (chronic) illness
  • Live with or have close contact with a person who has staph
  • Play contact sports or share athletic equipment
  • Share items such as towels, razors, or cosmetics with others
  • Recently stayed in a hospital or long-term care facility6

To avoid a staph infection, like impetigo, be sure to:

  • Keep your hands clean by washing them thoroughly with soap and water.
  • Keep cuts and scrapes clean and covered with bandages until they heal.
  • Avoid contact with other people’s wounds or bandages.
  • Do not share personal items such as towels, clothing, or cosmetics.6

For athletes, take extra precaution to:

  • Cover wounds with a clean bandage. Do not touch other people’s bandages.
  • Wash your hands well before and after playing sports.
  • Shower right after exercising. Do not share soap, razors, or towels.
  • If you share sports equipment, clean it first with antiseptic solution or wipes. Use clothing or a towel between your skin and the equipment.
  • Do not use a common whirlpool or sauna if another person with an open sore used it. Always use clothing or a towel as a barrier.
  • Do not share splints, bandages, or braces.
  • Check that shared shower facilities are clean. If they are not clean, shower at home.6

Diagnosis

History and physical exam are essential to the diagnosis of impetigo.  Bacterial cultures can be used for confirmation of diagnosis and should be obtained if methicillin-resistant staph aureus (MRSA) is suspected or if an impetigo outbreak is present.  A skin biopsy may be considered if the case is refractory (resistant to treatment). The anti-streptolysin O (ASO) response is weak from impetigo alone. Therefore, serologic testing for streptococcal antibodies is not indicated for the diagnosis of impetigo. However, it may be useful if post-streptococcal glomerulonephritis is suspected in a patient with a recent impetigo outbreak. Human immunodeficiency virus (HIV) testing should be considered when a previously healthy adult develops bullous impetigo.1

Treatment

According to the NIH, without treatment, the infection heals in 14-21 days. About 20% of cases resolve spontaneously. Scarring is rare but some patients may develop pigmentation changes. Some patients may develop ecthyma. With treatment, cure occurs within 10 days. Neonates may develop meningitis. A rare complication is acute post streptococcal glomerulonephritis, which occurs 2-3 weeks after the skin infection.1

Pharmaceutical Medications

Topical antibiotics such as mupirocin, retapamulin, or fusidic acid may be recommended by your healthcare provider. Be sure to read the manufacturer inserts for each (click on trade name for insert) especially the adverse reaction sections listing Clostridium difficile-Associated Diarrhea (CDAD), Potential for Microbial Overgrowth, and Risk of Polyethylene Glycol Absorption. Additionally, oral antibiotics may be recommended based on severity (amoxicillin / calvulanate, dicloaxacillin, clindamycin, doxycycline, or macrolides).

Generally, “when prescribing antibiotics, one should limit the duration to no more than 7 to 10 days for most infections. The reason is that the empirical prescription of antibiotics has led to the development of resistant strains.”7

According to the NIH, “Topical antimicrobials such as mupirocin can be used to eliminate nasal colonization in some nasal carriers. However, usage is controversial.”7

An important consideration for S. aureus decolonization is the emergence of staphylococcal strains resistant to topical antimicrobials, which has been demonstrated in vitro and in vivo. This resistance in turn predicts failure of S. aureus decolonization efforts and has led to hospital outbreaks with resistant strains. An additional concern is that the genes conferring resistance to mupirocin (most commonly mupA) and chlorhexidine (most commonly qac A/B or smr) are carried on plasmids that can also harbor genes conferring resistance to other systemic antibiotics.

National Institutes of Health

Alternatively, recent research from the NIH has revealed a “probiotic [that] reduced the amount of Staphylococcus aureus, or ‘staph,’ bacteria in the human gut and nose without harming beneficial gut microbes.”8

Decolonization—eliminating the symptom-free bacteria—could prevent harmful S. aureus infections. Previous decolonization strategies have used topical antibiotics or antiseptics to get rid of S. aureus from the nose or skin. These efforts have had limited success, likely because they don’t affect S. aureus in the gut. Decolonizing the gut would require oral antibiotics. But this risks harming the beneficial gut microbes that usually help prevent infections. It could also lead to more antibiotic resistance.

National Institutes of Health

In this research, it was discovered that “Bacillus subtilis, secretes molecules that inhibit S. aureus colonization. An oral probiotic containing live B. subtilis spores eliminated S. aureus from the guts of mice. This suggested that probiotics might decolonize S. aureus from the human gut without the risks that go with antibiotics.”8

The results suggest that B. subtilis probiotics could safely reduce S. aureus colonization in the human body. Such a strategy could help lower infection rates, particularly in high-risk settings such as nursing homes. This study also demonstrates the importance of targeting the gut for S. aureus decolonization in general. Decolonizing the gut led to a large reduction in S. aureus throughout the body. In contrast, decolonizing the nose only affects a small part of the body’s total S. aureus.

“The probiotic we use does not ‘kill’ S. aureus, but it specifically and strongly diminishes its capacity to colonize,” Otto says. “We think we can target the ‘bad’ S. aureus while leaving the composition of the microbiota intact.”

National Institutes of Health
Nutrition

As stated above, probiotics with B. subtilis may help with decolonization. Scroll to the “Products to Research” section for options.

As with any skin inflammation or bacterial infection, adopting an anti-inflammatory diet, getting enough sleep, maintaining proper vitamin levels, and minimizing stress all help your body heal.

Homeopathy

The below homeopathic remedies have helped others with impetigo, however it is recommended to work with a trained homeopath (in person or virtually). What works for one person may not work for another. First time trying homeopathy? Here’s a great quick start guide. Also, most homeopathy is HSA/FSA eligible.

Herbal Topical Products

For general skin disorders, the following herbs used in compresses or sitz baths can be helpful especially if the patient is itching: echinacea, chaparral, comfrey, plantain, marshmallow root, and cayenne. Mountain Rose Herbs is a great resource to purchase herbs to mix yourself.

Additionally, tea tree oil is commonly applied topically for treatment of bacterial and fungal infections. Tea tree oil has shown in vitro activity against a wide variety of microorganisms, including Propionibacterium acnes, Staphylococcus aureus, Escherichia coli, Candida albicans, Trichophyton mentagrophytes, and Trichophyton rubrum.5 However, be sure to properly dilute it. If it aggravates the skin versus helping, consider stopping administration.

For diaper areas, coconut oil or a mixture of comfrey, olive oil, and/or beeswax like this may help soothe irritated skin especially if the impetigo is bullous.

Colloidal Silver

Colloidal silver is highly debated, however a recent study found it to be an effective treatment of Staphylococcus aureus infection.9

Owing to the abuse of antibiotics, resistant bacteria emerge and make the treatment of infected wounds more difficult. Treatment of bacterially infected wounds with inorganic antimicrobials may address bacterial resistance. This study explored the antibacterial effects of silver nanoparticles (AgNPs) and Ag+ in vitro, and their therapeutic effects on staphylococcus aureus (S. aureus) infected wounds in vivo. By measuring the minimum inhibitory concentration, inhibition zone and anti-biofilm effect, it was found that AgNPs and Ag + have excellent antibacterial effects on S. aureus and methicillin-resistant staphylococcus aureus (MRSA), and Ag + showed better antibacterial effects than AgNPs in vitro.

Journal of Drug Delivery Science and Technology

In another study with mice, silver nanoparticles (AgNPs) showed ample antibacterial activities.10

Topical application of gentamicin and AgNPs (0.08 and 0.04 mg kg-1) significantly increased the rate of wound healing more than treatment with AgNPs at a dose of 0.02 mg kg-1and normal saline. The presence of silver nanoparticles in AgNPs groups (especially 0.08 mg kg-1) improved wound appearance better than other groups without silver nanoparticles (gentamicin and control groups) and led to lesser wound scars. According to data analysis, healing rate of treated mice with gentamicin and AgNPs (0.08 mg kg-1) was significantly (p < 0.001) faster than treated mice with other AgNPs doses and normal saline. The results of current study introduced an in vivo nanosilver accelerating effects on the treatment of on S. aureus infected skin wounds.

Due to prompt prevalence of multidrug-resistant pathogens and insufficient research regarding antibiotic production; the AgNPs could be useful alternatives of routine antibiotic therapy.

National Institutes of Health

Additionally, research has shown “silver nanoparticles have high therapeutic activity against MRSA, thus can be suggested as an alternative or adjuvant with antibiotics for MRSA treatment.”11

The results showed that the MRSA isolates were fully susceptible to the antibacterial effect of Ag-NPs over the MIC concentration. This proves the results obtained by other authors, which showed colloidal silver is a powerful antibiotic against a wide range of microorganisms at a very low concentration without having any harmful effect on body tissues. Small Ag-NPs with large surface areas provide an effective antimicrobial agent even at very low concentrations. Silver Nanoparticles (diameter of 5 – 100 nm) enhances the antibacterial activity of various antibiotics.

National Institutes of Health
Apple Cider Vinegar

Due to the rise of antibiotic-resistant bacteria, recent studies have also been conducted on Apple Cider Vinegar. One in particular states, “ACV impaired cell integrity, organelles and protein expression” of microbes including S. aureus.12 Anecdotally, diluted ACV applied to impetigo may help or using products like Rowe Casa Organics Skin Virus Drops (“JUSTTHEINSERTS” for 20% off first order) which contains ACV.

Other Antimicrobial products to research

Red Light Therapy | Manuka Honey (like this) | Aloe Vera | Chamomile | Garlic

Pediatric Tips

Since impetigo can spread to other parts of the body and to other people, try your best to prevent your child from scratching impetigo areas. Be sure to clip fingernails often. Anecdotally, full body footie pajamas made from organic materials help keep impetigo contained. Synthetic materials are typically not breathable and may expose your child to more toxins that need to be detoxed.

Organic disposable diapers or organic reusable diapers washed in hot water + changed often may help as well. Additionally, try to change bedsheets/pillows after every nap or bedtime to help limit exposure. Showering daily and washing towels in hot water after every use is also helpful. For impetigo on fingers, hypoallergenic bandages are great to prevent spread.

For all the recommendations mentioned in this post, be extra observant when using on a child. If your child screams in pain every time you administer a topical antibiotic or diluted tea tree oil, it may be too harsh for their skin or could be causing an allergic reaction. Try your best to find the best route for your child and remember what works for one child may not work for another. Similarly, one topical product may help in the beginning stages of impetigo and be less effective toward the end. Being adaptable + observant are keys to healing!

Caregiver Encouragement

If you are caring for a child with impetigo, be aware it is a demanding and sometimes long process. Some impetigo cases can take weeks to clear on its own. Staying close to make sure your child doesn’t scratch or navigating clinginess/irritability can be mentally and emotionally exhausting. The custodial tasks of changing bandages, applying ointments or salves, and constantly washing bedsheets and clothes are equally exhausting.

Be sure to take care of your health as well! It may be tempting to opt for processed foods or self-soothe with alcohol or sugar, however those choices may lower your immune response and add to an already stressful environment. Don’t be afraid to ask for help from trusted friends and family. Ensure you’re getting enough vitamin C and quality sleep too! To prevent colonization within the household, a daily probiotic with the products below may help.

Concerning non-toxic cleaning supplies, Rowe Casa Organics Immunity Hand Soap, Laundry Detergent, and Multi-Surface Cleaner are helpful. Use discount code “JUSTTHEINSERTS” for 20% off first order. Additionally, Probiome All Purpose Cleaner is great to keep surfaces clean.

1 National Institutes of Health

2 Centers for Disease Control and Prevention

3 Centers for Disease Control and Prevention

4 Joette Calabrese

5 National Institutes of Health

6 National Institutes of Health

7 National Institutes of Health

8 National Institutes of Health

9 Journal of Drug Delivery Science and Technology

10 National Institutes of Health

11 National Institutes of Health

12 National Institutes of Health

Products to Research

Topical Products

Probiotics

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