Interventions for impetigo.
BACKGROUND
Impetigo is a common superficial bacterial skin infection, most frequently encountered in children. There is no standard therapy and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants.


OBJECTIVE
To assess the effects of treatments for impetigo, including waiting for natural resolution.


METHODS
We searched the Skin Group Specialised Trials Register (March 2002), Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2002), the National Research Register (2002), MEDLINE (from 1966 to January 2003), EMBASE (from 1980 to March 2000) and LILACS (November 2001). We handsearched the Yearbook of Dermatology (1938-1966), the Yearbook of Drug Therapy (1949-1966), used reference lists of articles and contacted pharmaceutical companies.


METHODS
Randomised controlled trials of treatments for non-bullous and bullous, primary and secondary impetigo.


METHODS
All steps in data collection were done by two independent reviewers. We performed quality assessments and data collection in two separate stages.


RESULTS
We included 57 trials including 3533 participants in total which studied 20 different oral and 18 different topical treatments. CURE OR IMPROVEMENT: Topical antibiotics showed better cure rates than placebo (pooled odds ratio (OR) 6.49, 95% confidence interval (CI) 3.93 to 10.73), and no topical antibiotic was superior (pooled OR of mupirocin versus fusidic acid 1.76, 95% CI 0.69 to 2.16). Topical mupirocin was superior to oral erythromycin (pooled OR 1.22, 95% CI 1.05 to 2.97). In most other comparisons, topical and oral antibiotics did not show significantly different cure rates, nor did most trials comparing oral antibiotics. Penicillin was inferior to erythromycin and cloxacillin and there is little evidence that using disinfectant solutions improves impetigo.


RESULTS
The reported number of side effects was low. Oral antibiotic treatment caused more side effects, especially gastrointestinal ones, than topical treatment.


CONCLUSIONS
Data on the natural course of impetigo are lacking. Placebo controlled trials are scarce. There is little evidence about the value of disinfecting measures. There is good evidence that topical mupirocin and topical fusidic acid are equally, or more effective than oral treatment for people with limited disease. It is unclear if oral antibiotics are superior to topical antibiotics for people with extensive impetigo. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. Resistance patterns against antibiotics change and should be taken into account in the choice of therapy.
Koning
S
S
Department of General Practice, Erasmus MC - University Medical Center Rotterdam, Room Ff337, PO Box 1738, Rotterdam, Netherlands, 3000 DR.
Verhagen
A P
AP
van Suijlekom-Smit
L W A
LW
Morris
A
A
Butler
C C
CC
van der Wouden
J C
JC
D000284:Administration, Oral; D000287:Administration, Topical; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D006801:Humans; D007169:Impetigo / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic
D000900:Anti-Bacterial Agents