Impetigo in Children: Symptoms, Causes & Treatment

What Is Impetigo and How Common Is It?

Impetigo is a superficial bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes bacteria. It is one of the most common skin infections in children, affecting approximately 2% of children under age 5 each year, with peak incidence between ages 2 and 5 years.

Impetigo, sometimes called "school sores," is a skin infection that affects the outermost layers of the skin (epidermis). It gets its name from the Latin word meaning "attack," which reflects how quickly it can spread both on an individual child and between children in close contact. The infection is most prevalent during warm, humid months, though it can occur year-round in any climate.

The bacteria that cause impetigo are commonly found on the skin and in the nose of healthy people without causing problems. However, when these bacteria enter the skin through a small cut, insect bite, area of eczema, or irritated skin, they can multiply and cause infection. This is why impetigo often develops after a child has had a cold, since the skin around the nose and mouth becomes irritated from frequent wiping and blowing.

There are two main types of impetigo: non-bullous impetigo, which accounts for about 70% of cases and is characterized by the classic honey-colored crusts, and bullous impetigo, which features larger fluid-filled blisters. Both types are caused by bacteria and are equally contagious, though they may require slightly different treatment approaches.

While impetigo can affect people of any age, it is particularly common in young children because of their developing immune systems, tendency to have minor skin injuries from active play, and close physical contact with other children in daycare and school settings. Children with eczema or other conditions that compromise the skin barrier are at higher risk of developing impetigo.

What Are the Symptoms of Impetigo?

Impetigo typically begins as small red spots or blisters that rapidly develop into distinctive honey-colored or golden-yellow crusts. The sores most commonly appear around the mouth and nose, but can spread to other body parts. Symptoms may include itching, mild discomfort, and nearby lymph node swelling.

The symptoms of impetigo develop in a characteristic pattern that helps distinguish it from other skin conditions. Understanding this progression can help parents identify the infection early and begin appropriate treatment.

The infection typically begins with the appearance of one or more small red spots on the skin, often around the nose, mouth, or chin. These initial spots may look like small pimples or insect bites. Within a day or two, these spots develop into small blisters or vesicles filled with clear or slightly cloudy fluid. The skin around these blisters often appears red and may feel warm to the touch.

As the blisters mature, they become fragile and easily rupture, releasing their fluid contents. This fluid is highly contagious and contains large numbers of bacteria. When the fluid dries, it forms the characteristic honey-colored or golden-yellow crusts that are the hallmark of impetigo. These crusts may look thick and waxy, almost like dried honey has been spread on the skin.

New blisters and sores often appear adjacent to existing ones as the infection spreads through the release of bacterial-laden fluid. This can create clusters or patches of affected skin that gradually enlarge over time. Children may inadvertently spread the infection to other parts of their body by scratching the sores and then touching uninfected skin.

Common Locations for Impetigo

While impetigo can occur anywhere on the body, certain areas are more commonly affected. The face, particularly around the mouth and nose, is the most frequent location. This is partly because the skin in these areas often becomes irritated from colds, runny noses, or contact with food and saliva. Other common locations include:

• Behind the ears: A moist area that is prone to skin irritation
• On the fingers and hands: From touching infected areas or contaminated surfaces
• On the arms and legs: Often at sites of insect bites, scratches, or cuts
• On the trunk: Especially in areas where clothing causes friction

Additional Symptoms to Watch For

Beyond the visible skin changes, impetigo may cause other symptoms that parents should be aware of. Many children experience itching at the site of infection, which can range from mild to quite bothersome. This itching can lead to scratching, which in turn can spread the infection and potentially introduce other bacteria into the wounds.

In some cases, particularly when the infection is more extensive or has been present for several days, children may develop swollen lymph nodes near the affected area. For example, impetigo around the mouth may cause swelling of the lymph nodes under the jaw or in the neck. While this swelling indicates the body's immune response to the infection, it usually resolves as the impetigo heals.

What Causes Impetigo in Children?

Impetigo is caused by bacteria, primarily Staphylococcus aureus (staph) or Streptococcus pyogenes (strep), that enter the skin through minor breaks or areas of damaged skin. Risk factors include existing skin conditions like eczema, recent cuts or insect bites, close contact with infected individuals, and warm humid weather.

Understanding what causes impetigo can help parents take preventive measures and recognize situations where their children may be at higher risk. The bacteria responsible for impetigo are extremely common in our environment and often live harmlessly on the skin and in the noses of healthy people. Problems arise only when these bacteria gain entry through the skin barrier and begin to multiply in the underlying tissue.

Staphylococcus aureus is the most common cause of impetigo in developed countries, responsible for approximately 80% of cases. This bacterium is particularly adept at colonizing the skin and can produce toxins that contribute to the blistering seen in bullous impetigo. Group A Streptococcus (Streptococcus pyogenes), the same bacterium that causes strep throat, causes the remaining cases, sometimes in combination with staph bacteria.

The bacteria typically enter through breaks in the skin that may be too small to notice with the naked eye. Common entry points include minor scratches and cuts from play, insect bites that have been scratched, areas of eczema or dry skin, irritated skin around the nose and mouth from colds or allergies, and chickenpox lesions. Once the bacteria have established themselves, they multiply rapidly in the warm, moist environment of the skin, leading to the characteristic symptoms of impetigo.

Risk Factors for Developing Impetigo

While any child can develop impetigo, certain factors increase the likelihood of infection. Children with eczema or other chronic skin conditions have a compromised skin barrier that makes it easier for bacteria to enter. The constant itching and scratching associated with eczema also creates numerous tiny breaks in the skin.

Environmental factors play a significant role as well. Impetigo is more common during summer months when warm, humid conditions favor bacterial growth and children spend more time outdoors engaging in activities that lead to minor skin injuries. Crowded conditions, such as those found in daycare centers, schools, and sports teams, facilitate the spread of bacteria between children.

Poor hygiene practices increase the risk of impetigo, though it's important to note that impetigo can affect children from families with excellent hygiene. The key factors are the presence of bacteria, a break in the skin barrier, and conditions that allow bacterial growth. Children who have recently had a cold are at higher risk because the frequent wiping and blowing irritates the skin around the nose and mouth.

How Is Impetigo Treated at Home?

Mild impetigo can often be treated at home by gently washing the sores with soap and water twice daily, removing softened crusts with a wet compress, and keeping the area clean and dry. Treatment should continue until the sores have completely dried and crusts have fallen off, typically within one week.

Home treatment of mild impetigo focuses on reducing bacterial numbers through good hygiene practices, allowing the body's immune system to clear the remaining infection. When done consistently and correctly, home treatment is often sufficient for small, localized areas of impetigo that are not spreading rapidly.

The cornerstone of home treatment is thorough but gentle cleaning of the affected areas. Using mild liquid soap (bar soap can harbor bacteria) and warm water, gently wash the sores twice daily - once in the morning and once in the evening. Before washing, apply a wet compress or damp cloth to the crusts for several minutes to soften them. This makes the crusts easier to remove without causing pain or damaging the underlying healing skin.

After softening, carefully remove the loose crusts. This step is important because the crusts contain large numbers of bacteria that can spread to other areas. Removing them also allows any topical treatments to reach the underlying skin more effectively. Be gentle to avoid creating new wounds that could become infected. After washing, pat the area dry with a clean paper towel (which should be immediately discarded) rather than a cloth towel that could spread bacteria.

Some parents find it helpful to use an antiseptic wash containing chlorhexidine, which is available at pharmacies without a prescription. While not strictly necessary for mild cases, these washes can help reduce bacterial numbers more effectively than soap alone. Ask your pharmacist for recommendations appropriate for your child's age.

Tips for Successful Home Treatment

Consistency is key to successful home treatment. The washing routine must be maintained twice daily until the sores have completely healed, which typically takes about one week. Stopping treatment early because the sores look better can allow bacteria to regrow and the infection to return.

Keep your child's fingernails short and clean to reduce the risk of scratching and spreading the infection. Young children may benefit from wearing mittens at night to prevent unconscious scratching during sleep. If your child has difficulty leaving the sores alone, covering them with a light, breathable bandage during the day may help, though the area should be left uncovered at night to allow drying.

When Should You See a Doctor for Impetigo?

Seek medical care if impetigo sores don't improve within one week of home treatment, continue spreading, cover a large area, or if your child develops fever. Medical treatment with topical or oral antibiotics may be necessary for widespread, persistent, or complicated infections.

While mild impetigo often responds well to home treatment, there are several situations where medical evaluation and prescription treatment become necessary. Recognizing when to seek professional help ensures your child receives appropriate care and prevents potential complications.

You should contact your child's doctor or healthcare provider if the sores have not shown improvement after one week of consistent home treatment, the infection continues to spread despite treatment, the sores cover a large area of skin, new sores keep appearing in different locations, your child develops a fever along with the skin infection, the area around the sores becomes increasingly red, warm, or swollen (which may indicate deeper infection), or your child seems unusually unwell or is in significant discomfort.

Medical Treatment Options

When home treatment is insufficient, doctors may prescribe topical antibiotics (applied directly to the skin) or oral antibiotics (taken by mouth), depending on the extent and severity of the infection. Topical antibiotics such as mupirocin or fusidic acid are typically the first choice for localized impetigo, applied two to three times daily for about a week. These medications kill the bacteria causing the infection without affecting the rest of the body.

Oral antibiotics become necessary when impetigo is widespread, when topical treatment has failed, when there are multiple areas of involvement, or when deeper infection is suspected. Common oral antibiotics prescribed for impetigo include cephalexin, dicloxacillin, or amoxicillin-clavulanate. The full course of antibiotics must be completed even if the sores appear healed before the medication is finished.

Can Children with Impetigo Go to School or Daycare?

Children with impetigo should stay home from school or daycare while the sores are moist and weeping, as this is when they are most contagious. They can typically return once sores are completely dry, or after 24-48 hours of antibiotic treatment if sores can be covered.

Managing school and daycare attendance when your child has impetigo requires balancing your child's need for education and socialization against the responsibility to protect other children from infection. The key factor in determining when it's safe to return is the contagiousness of the sores.

Impetigo is most contagious while the sores are moist, weeping, or covered with fresh honey-colored crusts. During this phase, the fluid from the sores contains large numbers of bacteria that can easily spread to other children through direct contact or shared objects. For preschool-age children in daycare settings, where close physical contact is unavoidable and hygiene practices are difficult to maintain, it's generally recommended to keep children home until all sores are completely dry.

School-age children may be able to return to school earlier if certain conditions are met. If the sores can be completely covered with bandages and the child is mature enough to practice good hand hygiene consistently, they may be able to attend school before the sores are fully healed. However, they should avoid activities where the sores might become exposed or where close physical contact is involved, such as physical education, swimming, and contact sports.

Guidelines for Return to School

For children receiving antibiotic treatment, most schools and daycare facilities allow return after 24 to 48 hours of treatment, provided the sores can be covered and the child feels well enough to participate in normal activities. Check with your specific school or daycare for their policies, as requirements may vary.

When your child does return to school or daycare, pack extra bandages and hand sanitizer in their bag. Remind them not to share food, drinks, towels, or personal items with other children. Inform the teacher or caregiver about the infection so they can reinforce hygiene practices and watch for signs of spread to other children.

How Can You Prevent Impetigo from Spreading?

Prevent impetigo spread through frequent handwashing with soap, using separate towels and washcloths for the infected child, washing linens and clothing in hot water, keeping the child's nails short, covering sores when possible, and cleaning frequently touched surfaces.

Preventing the spread of impetigo requires attention to hygiene practices both for the infected child and for other family members. Because impetigo is highly contagious, taking proper precautions can prevent other children in the household or community from developing the infection.

Hand hygiene is the single most important preventive measure. Both you and your child should wash hands frequently with soap and water, particularly after touching or treating the sores, before eating or preparing food, and after using the bathroom. Teach your child to wash their hands for at least 20 seconds, making sure to scrub all surfaces including between the fingers and under the nails.

Designate personal items for the infected child that should not be shared with anyone else. This includes towels, washcloths, bed linens, hairbrushes, and any items that come into contact with the affected areas. Wash these items separately from other family laundry, using hot water (at least 60°C or 140°F) and regular detergent. Change bed linens, especially pillowcases if the sores are on the face, daily until the infection clears.

Household Precautions

Regular cleaning of frequently touched surfaces can help prevent bacterial spread. Wipe down doorknobs, light switches, bathroom fixtures, and any toys or objects the child frequently handles with disinfectant or soap and water. Stuffed animals and fabric toys that cannot be easily washed should be kept away from the infected child until healing is complete.

If possible, have the infected child sleep alone rather than sharing a bed with siblings. If separate rooms aren't available, at least use separate bedding and maintain as much distance as feasible. Discourage roughhousing or close physical play between siblings until the sores have healed.

Teaching your child not to touch or scratch the sores is challenging but important. Keep their fingernails short and clean to minimize damage if they do scratch. For very young children or during sleep, lightweight cotton mittens or socks over the hands can help prevent scratching.

Are There Any Complications from Impetigo?

Impetigo rarely causes serious complications when properly treated. Potential complications include cellulitis (deeper skin infection), ecthyma (a deeper ulcerative form), post-streptococcal glomerulonephritis (rare kidney inflammation), and scarring. Most children recover completely without long-term effects.

Parents naturally worry about potential complications from any childhood infection. The good news is that impetigo is typically a superficial infection that heals without lasting consequences when managed appropriately. However, being aware of potential complications helps ensure prompt treatment if problems develop.

The most common complication is the spread of infection to other skin areas, which occurs when hygiene measures are inadequate or the child scratches the sores. While not dangerous, spreading infection takes longer to heal and may require more intensive treatment. Rarely, the bacteria can penetrate deeper into the skin, causing cellulitis - a more serious infection of the deeper skin layers characterized by spreading redness, warmth, swelling, and sometimes fever. Cellulitis requires oral or intravenous antibiotics.

Ecthyma is a deeper, ulcerative form of impetigo that penetrates below the epidermis into the dermis. It appears as punched-out ulcers with thick crusts and may leave scarring after healing. Ecthyma is more common when impetigo is not treated promptly or when it occurs in people with weakened immune systems.

A rare but important complication associated with streptococcal impetigo is post-streptococcal glomerulonephritis, an inflammatory kidney condition that can develop one to two weeks after the skin infection. Signs include dark or bloody urine, decreased urine output, swelling (especially around the eyes), and elevated blood pressure. This condition usually resolves completely with appropriate management, but requires medical evaluation and monitoring.

Scarring is uncommon with typical impetigo because the infection remains superficial. However, ecthyma or secondarily infected wounds may leave permanent marks. Avoiding scratching and picking at the sores helps prevent scarring.

How Is Impetigo Different from Other Skin Conditions?

Impetigo can be confused with herpes cold sores, chickenpox, eczema, ringworm, or contact dermatitis. Key distinguishing features of impetigo include honey-colored crusts, rapid spread to nearby areas, absence of fever in most cases, and typical location around the mouth and nose.

Several skin conditions in children can look similar to impetigo, making accurate identification important for proper treatment. Understanding the differences helps parents decide when to try home care versus when to seek medical evaluation.

Herpes simplex (cold sores) can look similar to impetigo, particularly in the early blister stage, and both commonly affect the area around the mouth. However, cold sores typically appear as a cluster of small blisters at the same location each time, often preceded by tingling or burning. Cold sores are caused by a virus rather than bacteria and don't respond to antibiotic treatment. The crusts from cold sores are usually darker colored rather than the honey-yellow of impetigo.

Chickenpox also causes blistering skin lesions but differs from impetigo in several ways. Chickenpox blisters appear all over the body at once and are typically accompanied by fever and general illness. The rash in chickenpox starts on the trunk and spreads outward, with lesions at different stages present simultaneously. Chickenpox is now less common due to vaccination.

Eczema (atopic dermatitis) causes red, itchy, dry patches of skin that can sometimes be confused with early impetigo. However, eczema doesn't typically form blisters or honey-colored crusts. That said, impetigo can develop on top of eczema patches, so the two conditions may coexist. If eczema suddenly becomes weepy with yellow crusts, impetigo may have developed as a secondary infection.

Ringworm (tinea) creates red, circular, scaly patches with a slightly raised border. Despite the name, it's a fungal infection, not a worm. Ringworm doesn't form the blisters and honey-colored crusts characteristic of impetigo, and it spreads more slowly.