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Impetigo

★ CMTO Exam Focus

Impetigo is the most common superficial bacterial skin infection, caused primarily by Staphylococcus aureus or Streptococcus pyogenes. It presents as honey-colored crusted lesions, most frequently on the face, and is highly contagious through direct contact and fomites. Active impetigo is an absolute contraindication to massage. It predominantly affects children ages 2-5 but can occur at any age when the skin barrier is compromised (e.g., secondary to eczema).

Pathophysiology

  • Non-bullous (70%): Most common. Small vesicles rupture forming characteristic honey-colored crusts. Caused by S. aureus or S. pyogenes
  • Bullous (30%): Caused exclusively by S. aureus producing exfoliative toxins. Large, fragile blisters (bullae) with thin varnish-like crust
  • Bacteria enter through breaks in the skin barrier (cuts, insect bites, eczematous skin)
  • Highly contagious via direct contact with lesions or fomites (towels, linens)
  • Autoinoculation: Spreads to other body sites by scratching
  • Rare complication: post-streptococcal glomerulonephritis

Signs and Symptoms

Hallmark Indicators

  • Non-bullous: Honey-colored ("golden") crusts on an erythematous base. Commonly on face around nose and mouth
  • Bullous: Large, flaccid blisters (1-2 cm) with clear to yellow fluid. Thin shiny crust after rupture
  • Pruritus (itching) leading to scratching and autoinoculation
  • Regional lymphadenopathy may be present
  • Lesions spread rapidly if untreated

Red Flags and Rule-Outs

  • Highly contagious: Absolute contraindication until all lesions fully resolved and antibiotic course completed
  • Honey-colored crusts on eczematous skin: Secondary impetigo (impetiginization) — medical referral
  • Spreading despite treatment: May indicate MRSA — refer for culture
  • Distinguish from herpes: Herpes has clustered vesicles on erythematous base. Impetigo has honey crusts

MT Considerations

  • Absolute contraindication: Do not treat clients with active impetigo anywhere on the body
  • Reschedule: Postpone until antibiotic therapy complete and ALL lesions fully resolved (no crusting, no active lesions)
  • IPAC critical: If identified during session, stop treatment, sanitize all contacted surfaces and linens, wash hands/arms thoroughly
  • Fomite transmission: Bacteria survive on linens, face cradle covers, and equipment — thorough sanitization essential
  • Post-resolution: No ongoing contraindications. Residual hyperpigmentation is not a concern

CMTO Exam Relevance

  • Most common superficial bacterial skin infection
  • Honey-colored crusts on the face are the hallmark presentation
  • Highly contagious — absolute contraindication until fully resolved
  • Distinguish non-bullous (honey crusts) from bullous (large blisters)
  • Can complicate existing eczema (secondary impetigo/impetiginization)

Key Takeaways

  • Impetigo is the most common superficial bacterial skin infection, primarily in children
  • Honey-colored crusts on the face are the hallmark. Caused by S. aureus or S. pyogenes
  • Highly contagious via direct contact and fomites — absolute contraindication
  • Reschedule until antibiotics completed and all lesions fully resolved
  • IPAC protocols are critical to prevent cross-contamination

Related Conditions

Sources

  • Norris, T. L. (2019). Porth's essentials of pathophysiology (5th ed.). Wolters Kluwer.
  • Werner, R. (2020). A massage therapist's guide to pathology (7th ed.). Books of Discovery.
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