Most parents do not need a long article on impetigo — they need a clear answer about which cream, how long, and when their child can go back to nursery. This is that article. Impetigo is one of the most common bacterial skin infections in children under 5, it almost always responds quickly to treatment, and the key decisions are whether topical cream is enough or whether oral antibiotics are needed. For more on common childhood infections, visit Healthbooq.
How to Tell It's Impetigo
Two patterns cover almost everything you'll see.
Non-bullous impetigo is the common one. A red sore turns into a thin blister, which breaks within a day and dries into a yellow-gold crust — the "honey" or "cornflake" look. Usually around the nose, mouth, or chin, but it can land anywhere there is broken skin. Mild itch, no real pain. It is caused by Staphylococcus aureus, Streptococcus pyogenes (Group A Strep), or both.
Bullous impetigo is less common, almost always pure Staph, and shows up as larger fluid-filled blisters — sometimes 1–2 cm — that pop and leave a thin, shiny crust. It is more likely in babies and young infants and is the form a GP will treat with more caution.
If you are not sure whether something is impetigo, eczema, cold sores, or chickenpox, photograph it and book a same-week GP appointment. Cold sores (HSV) and impetigo can look similar early on, and the treatments are different.
First-Line Treatment for a Small Patch
NICE updated the impetigo guidance in 2020 to address antibiotic resistance, particularly to fusidic acid. The first-line topical for non-bullous impetigo on a localised area is now:
- Hydrogen peroxide 1% cream (Crystacide in the UK), available over the counter. Apply 2–3 times a day for 5 days, after gently softening crusts with warm water and patting dry. It is not an antibiotic — it works as an antiseptic — which is why it is preferred when the infection is small.
If hydrogen peroxide is not suitable (for example, around the eyes) or has not worked after a few days:
- Topical fusidic acid (prescription) three times daily for 5 days. In some regions, mupirocin is the equivalent first-choice topical antibiotic. Use only the prescribed course — do not save tubes for next time.
Apply with clean hands or a cotton bud, and wash your hands afterwards. Keep using the cream for the full course even if the crusts have gone within 2 days.
When Oral Antibiotics Are Needed
Tablets or syrup come in when the infection is doing more than sitting in one corner of the face. NICE and most UK paediatric protocols use them when:
- There are widespread sores, multiple body sites, or rapid spread.
- The child has bullous impetigo.
- Topical treatment hasn't worked after about a week.
- The child is a neonate or very young infant.
- The child is unwell — fever, lethargy, signs of spreading cellulitis.
- The child is immunocompromised or has significant eczema with secondary infection.
Flucloxacillin is the first-line oral antibiotic in the UK, typically for 5 days. Cefalexin is the usual alternative if flucloxacillin can't be used (poor palatability is a common reason — it tastes notoriously bad to children). Clarithromycin or erythromycin are options for penicillin allergy. In the US, cephalexin and dicloxacillin play similar roles.
How Long It Takes to Clear
With treatment, most localised impetigo improves visibly within 3 days and fully clears by 7 to 10 days. Without treatment, it usually self-resolves in 2 to 3 weeks but stays contagious for that whole time and can spread further on the same child.
If your child is still developing new sores after 5 days of correct treatment, go back to the GP. The likely options are: switching from topical to oral, swabbing for resistant Staph, or reconsidering whether something else (eczema flare, herpes, fungal infection) is at play.
Time Off Nursery and School
UK Health Security Agency (UKHSA) guidance: keep your child off nursery, school, or childcare until 48 hours after starting antibiotics, or until every sore is fully dried and crusted if you are managing without antibiotics.
This applies to topical antibiotics as well as oral. Hydrogen peroxide cream alone does not officially count toward the 48-hour exclusion, because it is not an antibiotic — in practice, follow your GP's specific advice. CDC and most European protocols are broadly equivalent: cover the lesions, treat them, return when no longer weeping.
Let the nursery know so they can watch for cases in other children.
Stopping It Spreading at Home
The basics, for about a week:
- Separate towel, flannel, and pillowcase for the affected child. Hot wash.
- Trim fingernails short — scratching is how impetigo travels from face to hand to elbow to sister.
- Wash hands before and after applying cream.
- Cover sores with a loose dressing where practical, especially on hands.
- No shared baths until the sores have crusted.
Impetigo on Top of Eczema
Eczematous skin is impetigo's favourite landing strip. The pattern looks slightly different: instead of a clear new crust on intact skin, you see existing eczema patches suddenly start weeping, becoming sticky and yellow-crusted, and spreading faster than usual.
If a child's eczema flares dramatically and topical steroids aren't pulling it back within a couple of days, suspect bacterial infection. Most GPs will start oral flucloxacillin alongside the usual eczema regimen. One trap: don't stop the steroid cream because the skin looks infected — uncontrolled eczema gets reinfected. Treat both at once.
A separate, more serious condition — eczema herpeticum (HSV on eczematous skin) — looks similar but with clusters of small punched-out sores and an unwell child. That is an urgent same-day assessment.
A Rare Late Complication
A small percentage of strep impetigo cases are followed, 1–3 weeks later, by post-streptococcal glomerulonephritis — a kidney inflammation that causes dark or tea-coloured urine, puffy eyes, and reduced urine output. It is rare and usually self-limiting, but if it happens, mention the recent skin infection so the GP makes the link quickly.
Key Takeaways
For a small patch of impetigo, NICE first-line is hydrogen peroxide 1% cream or topical fusidic acid for 5 days; for widespread or bullous infection, oral flucloxacillin. Most cases clear in 7–10 days, and your child can return to nursery 48 hours after starting antibiotics.
