Q6: Updated Guideline Question
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A 7-year-old girl is brought into the clinic by her concerned parents. They report that she developed several red lesions on her face 3 days ago, which have now progressed into yellow-crusted patches, predominantly around her nose and mouth. She is otherwise systemically well, with no signs of fever or malaise. On examination, you notice multiple yellow-crusted lesions on her cheeks, near the nose, and around her mouth. The child has no known allergies, and her vaccination history is up to date.
What is the most appropriate initial treatment for this child's condition based on the current guidelines?
A. Topical Clindamycin
B. Topical fusidic acid 2%
C. Hydrogen peroxide 1% cream
D. Oral Flucloxacillin
E. Topical Mupirocin 2% and Oral Flucloxacillin
Answer: C. Hydrogen peroxide 1% cream
Explanation
Background:
The patient is a 7-year-old girl presenting with characteristic yellow-crusted lesions that began as red spots, primarily localized around her nose and mouth.
Diagnosis:
The presentation strongly suggests a diagnosis of impetigo, a highly contagious skin infection commonly seen in children.
Reasoning Behind Answer Choices:
A. Topical Clindamycin: This is not a first-line treatment for impetigo and is reserved for resistant cases or those caused by Clindamycin-sensitive bacteria.
B. Topical fusidic acid 2%: Although a valid topical antibiotic for impetigo, it is not the first-line treatment as per updated guidelines.
C. Hydrogen peroxide 1% cream: According to the 2020 CKS update, this topical antiseptic (not an antibiotic) is the first-line treatment for localized non-bullous impetigo in patients who are systemically well and not at high risk of complications.
D. Oral Flucloxacillin: Generally reserved for more widespread impetigo or for patients who are systemically unwell.
E. Topical Mupirocin 2% and Oral Flucloxacillin: NICE guidelines specifically recommend against the combined use of topical and oral antibiotics for impetigo.
Management Guidelines:
The CKS (Clinical Knowledge Summaries) guidelines updated in 2020 recommend Hydrogen peroxide 1% cream as the initial management for localized non-bullous impetigo in patients who are not systemically unwell or at high risk of complications. It's essential to recognize that hydrogen peroxide is an antiseptic and not an antibiotic, yet it is still effective in treating localized impetigo.
Clinical Pearls:
1. Impetigo is highly contagious; thus, it's crucial to educate the family about hygiene measures to prevent its spread.
2. Re-evaluate the patient if the condition does not improve or worsens after the initial treatment.
3. A topical antibiotic like fusidic acid may be considered if a topical antiseptic is contraindicated, not tolerated, or ineffective.
Summary:
In summary, the child's clinical presentation and systemic well-being make localized non-bullous impetigo the most likely diagnosis. Hydrogen peroxide 1% cream is the recommended first-line treatment according to current guidelines.
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Reference:
The NICE guideline NG153 provides an overview of the antimicrobial prescribing strategy for impetigo, including advice to reduce the spread of infection, initial treatment, reassessment and further treatment, referral and seeking specialist advice, and choice of antimicrobial. It also includes a 2-page visual summary of the recommendations and tables to support prescribing decisions.
The NHS offers a brief summary of impetigo, its symptoms, causes, diagnosis, and treatment. It also advises when to see a GP and what to expect at the appointment.
The Primary Care Dermatology Society provides a comprehensive overview of impetigo, including its aetiology, history, clinical findings, investigations, and management. It also includes images of typical cases and differential diagnoses.
The CKS provides clinical knowledge summaries for impetigo, including background information, diagnosis, management, prescribing information, evidence, and patient information leaflets. It also includes an algorithm for the management of impetigo.
