Impetigo Treatments Compared
Why hydrogen peroxide comes before antibiotic creams, when tablets are needed, and how to apply any of it so it actually reaches the bacteria.
Part of the Complete Impetigo Guide.
Key fact: Hydrogen peroxide 1% cream is recommended before antibiotic creams for localised impetigo — not because it is milder, but because it works without driving resistance. Fusidic acid resistance in staph is a real problem, and repeated topical use for impetigo is a large part of why.
The order treatments are used in
| Situation | Treatment | Course |
|---|---|---|
| Localised non-bullous impetigo, not systemically unwell, not at high risk | Hydrogen peroxide 1% cream, two or three times a day | 5 to 7 days |
| Hydrogen peroxide unsuitable or ineffective | Fusidic acid 2% or mupirocin 2%, three times a day | 5 to 7 days |
| Widespread non-bullous impetigo | Topical or oral antibiotic, depending on the picture | 5 to 7 days |
| Bullous impetigo, systemically unwell, or high risk of complications | Oral antibiotic — flucloxacillin, or clarithromycin as an alternative, or erythromycin in pregnancy | 5 to 7 days |
Mupirocin is generally reserved for situations where resistant bacteria are suspected, which is part of keeping it working.
Hydrogen peroxide 1% cream
Sold as Crystacide, this is the recommended first step for localised impetigo.
- Applied two or three times a day for 5 to 7 days
- Not an antibiotic — it kills bacteria by oxidation rather than by a mechanism they can develop resistance to
- Comparable effectiveness to topical antibiotics for localised impetigo, which is why it is placed first
- Mild stinging or redness is the usual side effect
- Keep it away from the eyes, and avoid contact with hair and fabric, which it can bleach
If you were expecting an antibiotic, this is not a downgrade. It is the guideline, and the reasoning is straightforward: impetigo is common, it is usually mild, and using an antibiotic cream every time is how a useful antibiotic stops working.
Fusidic acid and mupirocin
| Fusidic acid 2% | Mupirocin 2% | |
|---|---|---|
| Product | Fucidin cream | Bactroban ointment |
| How often | Three times a day | Three times a day |
| Course | 5 to 7 days | 5 to 7 days |
| When used | Second line, where hydrogen peroxide is unsuitable or has not worked | Usually where resistance is suspected, or fusidic acid is unsuitable |
| Main concern | Resistance with repeated use | Kept in reserve to preserve it |
Both are effective. The reason they are second line is not efficacy but stewardship.
Oral antibiotics
Tablets or liquid are used when the infection is widespread, when it is bullous, when the person is systemically unwell, or when there is a high risk of complications.
- Flucloxacillin is the usual first choice — four times a day for 5 to 7 days
- Clarithromycin is the alternative, twice a day, including in penicillin allergy
- Erythromycin is used in pregnancy, four times a day
- Four times a day means four times a day — flucloxacillin is also better absorbed on an empty stomach, which makes it genuinely awkward to take properly
- A skin swab may be taken if resistant bacteria are suspected or treatment has failed
Why the order matters
Impetigo is one of the most common reasons topical antibiotics are prescribed, and topical use is particularly good at selecting for resistance because the drug sits on colonised skin at varying concentrations for days.
Fusidic acid resistance in Staphylococcus aureus rose substantially in the UK in step with topical prescribing for skin infection. Putting hydrogen peroxide first is a deliberate response to that — it treats the individual case without spending a resource everyone depends on.
Do not reuse a leftover tube of antibiotic cream for the next episode, or pass it to someone else. Repeated short bursts of topical antibiotic are the pattern that drives resistance most efficiently, and a fresh assessment costs nothing.
Applying it properly
| Step | What it involves |
|---|---|
| Wash your hands first | And again afterwards, every time |
| Soak off the crusts gently | Warm water and a clean cloth. Cream cannot reach bacteria under a thick crust. Do not pick them off dry |
| Apply a thin layer | Covering the sores and a small margin of surrounding skin |
| Cover loosely if practical | Particularly on a child who will touch it |
| Use a separate cloth and towel | Washed hot, not shared |
| Do not share the tube | Between people, or between this episode and a later one |
How long, and when to stop
Five to seven days, and finish the course. Improvement is usually visible within a few days, and stopping at that point is the commonest reason impetigo returns a week later.
Seek advice if symptoms worsen at any point, or if there is no improvement by the end of the course — both are reasons to reassess rather than to repeat the same treatment.
If it is not working
| Possibility | What it means |
|---|---|
| It is not impetigo | See is it impetigo? — ringworm, eczema herpeticum and contact dermatitis do not respond to any of this |
| Something underneath | Uncontrolled eczema, scabies or scratched bites keep providing new broken skin |
| Crusts not removed | Cream applied over a thick crust does not reach the bacteria beneath it |
| Reinfection at home | Shared towels, unwashed bedding, or another person carrying it |
| Resistant bacteria | A skin swab identifies this, and changes the choice |
| It needed oral treatment | Widespread or bullous impetigo does not clear with topical treatment alone |
Children and babies
Do not self-treat a baby under 1 year old — get them assessed. The same applies if you are breastfeeding and the breasts are affected, if the immune system is weakened, if the blisters are large and fluid-filled, or if a child has fever or seems unwell. Bullous impetigo in a newborn in particular needs prompt medical assessment.
Doses for children are weight- and age-dependent, and the topical options are the same medicines at the same strengths. The practical difficulty with children is not the medicine but keeping their hands off it and their nails short.
For localised impetigo, hydrogen peroxide 1% cream is recommended first, applied two or three times a day for 5 to 7 days. If it is unsuitable or has not worked, a topical antibiotic such as fusidic acid 2% or mupirocin 2% is used three times a day for 5 to 7 days. Because it is comparably effective for localised impetigo without contributing to antibiotic resistance. Fusidic acid resistance in Staphylococcus aureus has risen in step with topical prescribing for skin infection, so antibiotic creams are deliberately held back for cases that need them. When the infection is widespread, when it is the bullous type with large fluid-filled blisters, when the person is systemically unwell, or when there is a high risk of complications. Flucloxacillin is the usual choice, with clarithromycin as an alternative and erythromycin in pregnancy, for 5 to 7 days. Gently soften and remove them with warm water and a clean cloth, because cream cannot reach bacteria underneath a thick crust. Do not pick them off dry. Wash your hands before and afterwards, and use a cloth and towel that are not shared. It is better not to. Repeated short courses of topical antibiotic are an efficient way to drive resistance, and the current episode may not need an antibiotic at all, since hydrogen peroxide is first line for localised impetigo. A fresh assessment also checks it is still impetigo.Frequently Asked Questions
What is the best cream for impetigo?
Why is hydrogen peroxide used instead of an antibiotic?
When are antibiotic tablets needed for impetigo?
Should I remove the crusts before applying cream?
Can I use a leftover tube of Fucidin?
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.