Impetigo
2-minute consultation reviewed by a UK clinician
We check your answers and recommend a suitable option
Plain packaging to your door, fast and confidential
Impetigo: Symptoms, Treatment and the 48-Hour Rule
Why the first-line treatment is not an antibiotic, how long it stays contagious, and when a cream is not enough.
Key fact: The first-line treatment is not an antibiotic. For localised impetigo, NICE recommends hydrogen peroxide 1% cream first, with antibiotics held back for when it is unsuitable, ineffective, or the infection is widespread. Being handed a non-antibiotic cream is the guideline working, not a lesser option.
What impetigo is
Impetigo is a superficial bacterial infection of the skin, usually caused by Staphylococcus aureus and sometimes by Streptococcus pyogenes. It is the commonest bacterial skin infection in children, and it is very contagious.
It is superficial by definition — it sits in the outer layers of the skin, which is why it responds to treatment applied on top, and why it does not usually scar.
The two types
| Non-bullous | Bullous | |
|---|---|---|
| How common | The large majority of cases | Less common |
| What it looks like | Red sores that burst quickly and dry into golden-brown crusts — the NHS describes them as looking "a bit like cornflakes stuck to your skin" | Fluid-filled blisters, often larger, which burst to leave a raw area with a scaly edge |
| Where | Typically around the nose and mouth, and on the hands and limbs | Often the trunk, arms and legs; the nappy area in babies |
| Who | Any age, commonest in young children | More often babies and very young children |
| Treatment | Topical first if localised | Oral antibiotics — topical treatment is not used alone |
Impetigo can also develop on top of skin that is already damaged — eczema, a cold sore, a cut, an insect bite, scabies. That is called secondary impetigo, and it means treating both problems.
Who gets it
- Children aged two to five most of all, and anyone in close contact with them
- People with eczema, because broken skin is the way in — see eczema and dermatitis
- Anyone with a break in the skin — cuts, bites, grazes, cold sores
- Close-contact settings — nurseries, schools, households, contact sports
- Warm, humid weather, which is why it clusters in late summer and early autumn
- People carrying staph in the nose, which is the usual explanation for repeated episodes
How it spreads
By direct contact with the sores, and by anything that has touched them — towels, flannels, bedding, clothing, toys, sports equipment. It also spreads on the person themselves: scratching one patch and touching elsewhere starts a new one.
That first figure is the practical argument for treating it rather than waiting it out: treatment shortens the contagious period from up to three weeks to two days.
Treatment
| Situation | Treatment |
|---|---|
| Localised non-bullous impetigo, not systemically unwell | Hydrogen peroxide 1% cream, applied two or three times a day for 5 to 7 days |
| If hydrogen peroxide is unsuitable or has not worked | A topical antibiotic — fusidic acid 2% or mupirocin 2%, three times a day for 5 to 7 days |
| Widespread impetigo | A topical or oral antibiotic, depending on the picture |
| Bullous impetigo, systemically unwell, or high risk of complications | Oral antibiotics — usually flucloxacillin, with clarithromycin as an alternative, or erythromycin in pregnancy. 5 to 7 days |
Why hydrogen peroxide comes first. It works on the bacteria without being an antibiotic, so it does not contribute to resistance. Fusidic acid resistance in staph is a real and growing problem, driven largely by repeated topical use for exactly this condition — which is why the antibiotic creams are deliberately held in reserve. Treatments compared covers each option.
How long it takes
- Treatment courses run 5 to 7 days, whichever option is used
- Improvement is usually visible within a few days
- Finish the course even once it looks better — stopping early is the commonest reason it returns
- Get reassessed if it is worse, or no better by the end of the course
- It does not normally scar, though skin can stay discoloured for weeks afterwards
School, nursery and work
Stay away from school, nursery or work until 48 hours after starting treatment, or until all the sores have crusted over and healed if no treatment is being used. The 48-hour rule is the reason treatment is worth starting promptly — untreated, the exclusion period runs for as long as the sores are active.
Impetigo, school and stopping the spread covers the practicalities, including sport, swimming and what to tell the setting.
Stopping it spreading at home
- Do not touch or scratch the sores, blisters or crusts — the single most effective measure, and the hardest with a young child
- Wash hands thoroughly before and after applying cream, and regularly otherwise
- Keep nails short to limit damage from scratching
- Separate towel and flannel, not shared with anyone
- Wash bedding, towels and clothing at a high temperature, and change them daily while active
- Do not share toys, sports equipment, razors or bath water
- Cover the sores loosely where practical
If it keeps coming back
Recurrent impetigo usually has an explanation worth finding rather than being bad luck:
- Nasal carriage of staph — the bacteria live harmlessly in the nostrils and reseed the skin. This can be treated
- Underlying eczema that is not well controlled, leaving broken skin available
- Scabies, head lice or another itchy condition causing the scratching that lets bacteria in
- Someone else in the household carrying it, so it passes back and forth
- Courses stopped early, repeatedly
Frequently recurring impetigo is a reason to be assessed rather than to buy another tube.
When it needs more than a cream
Get medical advice rather than self-treating if: the person is under 1 year old; you are breastfeeding and the breasts are affected; the immune system is weakened by illness or medication; the blisters are large and fluid-filled (bullous impetigo); the rash is widespread or spreading quickly; there is fever or the person is generally unwell; or impetigo keeps coming back. Seek urgent help for a spreading red, hot, swollen, painful area around the sores, which can indicate cellulitis, or if a child becomes drowsy, very unwell or develops a widespread rash with fever.
Complications are uncommon but real: cellulitis, and rarely scarlet fever or a kidney inflammation following streptococcal infection. They are the reason impetigo is treated rather than left.
Frequently Asked Questions
How long is impetigo contagious?
It stops being contagious 48 hours after starting hydrogen peroxide cream or antibiotics. Without treatment it can take between 7 and 21 days to stop being contagious, which is the main practical argument for treating it promptly rather than waiting.
Why was I given a cream that is not an antibiotic?
Because that is the recommended first-line treatment. NICE advises hydrogen peroxide 1% cream for localised non-bullous impetigo in people who are not systemically unwell, applied two or three times a day for 5 to 7 days. It works without contributing to antibiotic resistance, which matters because fusidic acid resistance is a growing problem.
When can my child go back to school with impetigo?
48 hours after starting treatment. If no treatment is being used, they need to stay away until all the sores have crusted over and healed, which can take one to three weeks.
What does impetigo look like?
Most commonly red sores that burst quickly and dry into golden-brown crusts, often around the nose and mouth, described by the NHS as looking a bit like cornflakes stuck to the skin. The less common bullous type produces larger fluid-filled blisters that burst to leave a raw area.
Does impetigo leave scars?
It does not normally scar, because the infection is confined to the outer layers of the skin. The affected skin can stay discoloured for some weeks after it has healed, which fades.
Why does my child keep getting impetigo?
Usually there is a reason worth finding: staph bacteria living harmlessly in the nostrils and reseeding the skin, poorly controlled eczema leaving broken skin, an itchy condition causing scratching, someone else in the household carrying it, or courses stopped early. Recurrent impetigo is a reason to be assessed.
References
- National Institute for Health and Care Excellence. Impetigo: antimicrobial prescribing (NG153). nice.org.uk
- NHS. Impetigo. nhs.uk
- National Institute for Health and Care Excellence. Clinical Knowledge Summary: Impetigo. cks.nice.org.uk
- UK Health Security Agency. Health protection in children and young people settings, including education. gov.uk
- NHS. Cellulitis. nhs.uk
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Impetigo is highly contagious, and a spreading rash with fever or a child who is unwell needs assessment rather than a cream. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.
