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EDITORIALS: Sander Koning and Johannes C van der Wouden Treatment for impetigo BMJ 2004; 329: 695-696 [Full text]

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Paint it blue

Roderic S MacDonald   (4 October 2004)

Save mupirocin

Inge Axelsson   (11 October 2004)

Treatment of impetigo for whom?

Malcolm I McDonald, Bart Currie, David Brewster, Jonathan Carapetis   (18 October 2004)

Paint it blue 4 October 2004
Roderic S MacDonald, Specialist in musculoskeletal medicine London W4 2NL Send response to journal: Re: Paint it blue	In their editorial "Treatment of impetigo" [Ibid. 25th September Pp 695-6]the authors discuss the relative merits of systemic and topical antibiotics that were reported in their recent Cochrane review and add that they have no evidence to support the therapeutic value of disinfecting agents which they note have hardly been studied. They comment "Studies establishing the value of disinfecting agents are therefore most welcome". Generations of general practitioners have treated impetigo with gentian violet and while there has been some trial evidence that its effectiveness extends to MRSA [1], the main support for its use is clinical experience passed on from one practitioner to the next and reinforced by the rapid resolution they see when failures with more cosmetically acceptable topical antibiotic preparations lead on to a trial of gentian violet. The processes developing evidence-based practice must be able to promote those treatments that have been reliably proven while somehow preventing the loss of longstanding effective remedies for which there will never be a commercial imperative to fund trials. Surveys that aggregate the collective experience of practitioners and identify treatments that are perceived as effective but have not been evaluated, should trigger investigation perhaps through the Health Technology Assessment route rather than abandoning the treatment and sending another baby down the plug hole with the bath water. For those who might be stimulated by this letter to try gentian violet applications for impetigo, it should be noted that it should be kept away from the cornea. References : Okamo M et al. "Topical gentian violet for cutaneous infections and nasal carriers with MRSA." Int. Jnl. of Dermatology 2000; 39(12) : 942 - 4. Competing interests: None declared
Save mupirocin 11 October 2004
Inge Axelsson, associate professor Department of Health Sciences, Mid-Sweden University, SE 831 25 Ostersund, Sweden Send response to journal: Re: Save mupirocin	Drs Koning and van der Wouden write that "[Guidelines] may contain policies to reserve certain antibiotics for the treatment of other, more serious infections. For example, systemic fusidic acid is considered vital in the treatment of severe bone infections, and mupirocin is a cornerstone in eradication of methicillin resistant S aureus [MRSA]carriage." The Swedish Medical Products Agency (MPA; www.mpa.se) would probably agree. They recommended Swedish physicians and nurses not to use neither fusidic acid nor mupirocin topically. Fusidic acid-resistant S aureus has rapidly spread over Sweden, and we are very anxious to save mupirocin to help us maintain our favourable MRSA situation. Impetigo should be treated with soap and water, or with oral antibiotics, according to MPA, and I agree. inge.axelsson@mh.se Competing interests: None declared
Treatment of impetigo for whom? 18 October 2004
Malcolm I McDonald, physician Menzies School of Health Research, PO Box 41096 Casuarina, 0811, NT, Australia, Bart Currie, David Brewster, Jonathan Carapetis Send response to journal: Re: Treatment of impetigo for whom?	Sir - The editorial by Koning and van der Wouden advocated topical treatment for impetigo, specifically with mupirocin or fusidic acid;1 these recommendations were based on their Cochrane review. The authors failed to make it clear that these guidelines do not necessarily apply to developing countries with the greatest burden of disease and where group A streptococcus (GAS) is often the predominant pathogen. Impetigo in these settings commonly involves widespread areas of skin, frequently with underlying scabies infection.2 Experience tells us that there is a good response to benzathine penicillin, although scabies must be diagnosed and treated appropriately to prevent pyoderma recurrence. There are few randomised controlled trials to back up these observations, but unproven does not mean without effect. Clinical trials require considerable infrastructure and logistic support and are much more likely to be conducted in wealthier countries. For quality reasons, these are also more likely to be included in systematic reviews. A large part of the overall picture may be missing.3 From a developing country perspective, the recommended topical agents are expensive and beyond the financial reach of the families with the highest rates of disease. Considerable quantities of medication would be required to treat patients with generalised impetigo and compliance is likely to be low. The Cochrane reviews and the BMJ are readily accessible in developing countries and this editorial could be detrimental if clinicians change unnecessarily to expensive topical agents. Widespread use also carries the risk of developing drug resistance.4 The current challenge is to establish clinical trials of treatment options that are affordable, bacteriologically relevant and practically achievable in high-incidence settings.5 At the same we should endeavour to document the role of macrolide resistant GAS and methicillin-resistant Staphylococcus aureus. Malcolm McDonald, Bart Currie Menzies School of Health Research, PO Box 41096 Casuarina, 0811, Australia David Brewster Vila Central Hospital, Port Vila, Vanuatu Jonathan Carapetis University of Melbourne Department of Paediatrics, Parkville, 3052, Australia 1. Koning S, van der Wouden J. Treatment for impetigo: evidence favours topical treatment with mupirocin, fusidic acid. BMJ 2004;329:695- 6. 2. Currie BJ, Carapetis JR. Skin infections and infestations in Aboriginal communities in northern Australia. Australas J Dermatol 2000;41(3):139-43. 3. Lowe M. Evidence-based medicine - the view from Fiji. Lancet 2000;356:1 -3. 4. Udo EE, Pearman JW, Grubb W. Emergence of high-level mupirocin resistance in methicillin-resistant Staphylococcus aureus in Western Australia. J Hosp Infect 1994;26:157-65. 5. Page J, Heller RF, Scott K, Lim LLY, Qain W, Suping Z, et al. Attitudes of developing world physicians to where medical research is performed and reported. BMC Public Health 2003;3:6-14. Competing interests: None declared