Derm Cases · Dermatology / Infectious Diseases / Paediatrics
OSCE — honey-crusted facial lesions: impetigo recognition and treatment
An 8-minute OSCE station on non-bullous versus bullous impetigo, SSSS red flags, first-line topical and oral antibiotics with doses, school exclusion, decolonisation, and post-streptococcal complication counselling.
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Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on non-bullous versus bullous impetigo, SSSS red flags, first-line topical and oral antibiotics with doses, school exclusion, decolonisation, and post-streptococcal complication counselling.
Brief (to candidate)
A 4-year-old child has 5 days of mildly itchy facial and arm lesions. Examination shows clustered honey-coloured crusts on the peri-oral skin and a few satellite papulovesicles on the forearm; the child is afebrile and systemically well. A younger sibling shares a towel. You have 8 minutes to diagnose, treat, counsel on contagion and red flags, and plan follow-up.
[6]Candidate instructions
- Recognise non-bullous impetigo and name the main pathogens.
- Distinguish bullous impetigo, ecthyma, and SSSS red flags.
- Prescribe first-line therapy with drug, dose/frequency and duration for localised disease.
- State when to escalate to oral antibiotics and which agents.
- Counsel hygiene, school exclusion, contacts and decolonisation if recurrent.
- Safety-net PSGN and systemic deterioration.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Honey-coloured (golden) crusts on face/extremities after rupture of vesicles/pustules = non-bullous impetigo (~70%); S. aureus ± group A Streptococcus[1][3] |
| Variants & red flags | Bullous = flaccid bullae (staphylococcal exfoliative toxin); ecthyma = deeper ulcerative; SSSS = widespread tender superficial desquamation in infant/young child → admit IV anti-staphylococcal Rx; fever, lymphangitis, periorbital disease in neonate → escalate |
| Localised Rx | Gentle crust removal; mupirocin 2% ointment TDS × 5 days or fusidic acid 2% TDS × 5–7 days (or retapamulin 1% BD × 5 days where available); cover lesions; hand hygiene[4][2] |
| Extensive / oral Rx | Oral flucloxacillin 500 mg QDS (adult dose; paediatric weight-based) or cephalexin for ~7 days if extensive, bullous, or systemic features; MRSA options (clindamycin/TMP-SMX) per local resistance |
| Public health | Exclude from school/nursery until 24 h of effective treatment (or lesions crusted per local policy); no towel sharing; treat concurrent atopic dermatitis if present |
| Recurrence | Decolonisation: intranasal mupirocin 2% BD × 5 days + chlorhexidine body wash + hot laundry of towels/linen; treat household if recurrent |
| Complications & communication | Warn post-streptococcal glomerulonephritis 1–3 weeks later (dark urine, oedema, hypertension) — not prevented by antibiotics once infection established; return if fever, rapid spread, or infant skin peeling |
Model key actions
- Diagnose localised non-bullous impetigo from honey crusts + contacts.[1]
- Mupirocin 2% TDS × 5 days (or fusidic acid 2% TDS × 5–7 days) after crust soaks; school exclusion 24 h after starting Rx.[4][2]
- Safety-net SSSS, cellulitis, and PSGN symptoms.
Common errors
- Using topical steroids alone for crusted facial lesions.
- Oral antibiotics for few localised lesions without indication.
- Missing SSSS in a febrile infant with widespread tender erythema/desquamation.
- No school/hygiene advice; ignoring recurrent carriage decolonisation.
- Forgetting PSGN counselling after streptococcal impetigo.
References6ShowHide
- [1]Hartman-Adams H, Banvard C, Juckett G. Impetigo: diagnosis and treatment. American Family Physician, 2014.PMID 25250996
- [2]Trang DT, Buck EC, Schoenherr DT. Impetigo: Rapid Evidence Review. American Family Physician, 2026.PMID 41839109
- [3]Pereira LB. Impetigo - review. Anais Brasileiros de Dermatologia, 2014.PMID 24770507
- [4]Koning S, van der Sande R, Verhagen AP, et al. Interventions for impetigo. Cochrane Database of Systematic Reviews, 2012.PMID 22258953
- [5]Primhak S, Gataua A, Purvis D, et al. Treatment of Impetigo with Antiseptics-Replacing Antibiotics (TIARA) trial: a single blind randomised controlled trial in school health clinics within socioeconomically disadvantaged communities in New Zealand Trials, 2022.PMID 35109906
- [6]Vogel A, Lennon D, Best E, Leversha A. Where to from here? The treatment of impetigo in children as resistance to fusidic acid emerges N Z Med J, 2016.PMID 27736855