Impetigo is the most common bacterial skin infection in children two to five 
years of age. There are two principal types: nonbullous (70% of cases) and 
bullous (30% of cases). Nonbullous impetigo, or impetigo contagiosa, is caused 
by Staphylococcus aureus or Streptococcus pyogenes, and is characterized by 
honey-colored crusts on the face and extremities. Impetigo primarily affects the 
skin or secondarily infects insect bites, eczema, or herpetic lesions. Bullous 
impetigo, which is caused exclusively by S. aureus, results in large, flaccid 
bullae and is more likely to affect intertriginous areas. Both types usually 
resolve within two to three weeks without scarring, and complications are rare, 
with the most serious being poststreptococcal glomerulonephritis. Treatment 
includes topical antibiotics such as mupirocin, retapamulin, and fusidic acid. 
Oral antibiotic therapy can be used for impetigo with large bullae or when 
topical therapy is impractical. Amoxicillin/clavulanate, dicloxacillin, 
cephalexin, clindamycin, doxycycline, minocycline, 
trimethoprim/sulfamethoxazole, and macrolides are options, but penicillin is 
not. Natural therapies such as tea tree oil; olive, garlic, and coconut oils; 
and Manuka honey have been anecdotally successful, but lack sufficient evidence 
to recommend or dismiss them as treatment options. Treatments under development 
include minocycline foam and Ozenoxacin, a topical quinolone. Topical 
disinfectants are inferior to antibiotics and should not be used. Empiric 
treatment considerations have changed with the increasing prevalence of 
antibiotic-resistant bacteria, with methicillin-resistant S. aureus, 
macrolide-resistant streptococcus, and mupirocin-resistant streptococcus all 
documented. Fusidic acid, mupirocin, and retapamulin cover 
methicillin-susceptible S. aureus and streptococcal infections. Clindamycin 
proves helpful in suspected methicillin-resistant S. aureus infections. 
Trimethoprim/sulfamethoxazole covers methicillin-resistant S. aureus infection, 
but is inadequate for streptococcal infection.