Treatment for impetigo
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7468.695 (Published 23 September 2004) Cite this as: BMJ 2004;329:695All rapid responses
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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.
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests