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impetigo

Impetigo

Discussion

Related Terms: Impetigo, Soft tissue infection, lymphedema, antibiotic, bacteria, bacterial infection, Scarlet fever, Osteomyelitis, Pneumonia, Septicemia, Guttatre psoriases, zinc, supplementation, morbidity, infant, photograph, acute lower respiratory infection

Impetigo is a common skin infection, generally effecting children more so then adults. Statistics indicate that approximately 10% of skin infections/problems that occur in the US are cases of impetigo.

The exception is the lymphedema patient. Due to the immunocompromised condition of our lymphedematous limb, we are much more susceptible to infections. In fact, if discussions in our online support groups is any indication, impetigo is the third most common infection we come down with. It is very much one of those infections associated with lymphedema. So it is important that we understand what it is and how we can effectively treat it.

Years ago, my daughter and I caught impetigo from what we thought was an immaculate swimming pool. Hers was quickly brought under control, while mine just as quickly turned into an incredibly severe form of cellulitis.

Types of Impetigo

There are two types of impetigo. They are bullous impetigo and non bullous impetigo

Bullous Impetigo

Bullous impetigo results from invasion by phage group 2 S aureus onto either intact or disrupted skin. This occurs after colonization of the upper respiratory tract, usually involving the nares. Invasion is believed to be a result of an epidermolytic toxin that disrupts epidermal cell attachments.

Bullous impetigo usually has a history of thin-roofed bullae that spontaneously rupture without a history of localized lymphadenopathy or cutaneous disruption.(1)

Bullous lesions

  • Thin-roofed bullae that spontaneously rupture are present.
  • Bullous lesions usually spread locally in the face, trunk, extremities, buttocks, or perineal regions.
  • These lesions may secondarily invade preexisting lesions (eg, eczema) to cause generalized lesions.
  • Minimal or no surrounding erythema occurs.
  • No regional lymphadenopathy occurs.

Nonbullous Impetigo

In nonbullous impetigo, a tiny pustule or honey-colored crusted plaque with rapid spread, occasional pruritus, and regional lymphadenopathy may follow a break in the skin. (1)

Nonbullous lesions

  • Lesions start as tiny pustules that evolve rapidly into honey-colored crusted plaques, which usually measure less than 2 cm in diameter.
  • A rash is usually found in exposed areas of the face and extremities where bites, abrasions, lacerations, scratches, burns, or trauma have occurred.
  • Rapid spread occurs.
  • Lesions are usually asymptomatic, with occasional pruritus.
  • Little or no surrounding erythema or edema is present.
  • Regional adenopathy is common.

Causes of Impetigo

Causes of impetigo include Staphylococci (staph) and less frequently Streptocci (Strep). A person becomes infected through any opening, crack, lesion or cut in the skin. These “breaks” can include insect bites, animal bites, or human bites, or other injury or trauma to the skin. Impetigo may occur on skin where there is no visible break

Complications of Impetigo

  • Cellulitis
  • Suppurative Lymphadenitis
  • Staphylococal scalded skin syndrome
  • Scarlet fever
  • Osteomyelitis
  • Pneumonia
  • Septicemia
  • Guttatre psoriases

Transmission of Impetigo

Impetigo is highly contagious and is quickly spread through contact with an infected person.

This contact can include even sharing towels with an infected person.

It is also transmitted by direct contact with the lesions.

Symptoms of Impetigo

Impetigo begins as an itchy red sore that blisters, oozes and finally crusts. It then spreads quickly unless promptly treated.

Generalized symptoms include:

Skin lesion on the face or lips, or on the arms or legs, spreading to other areas. Typically this lesion begins as a cluster of tiny blisters which burst, followed by oozing and the formation of a thick honey- or brown-colored crust that is firmly stuck to the skin.

Itching blister:

  • Filled with yellow or honey-colored fluid
  • Oozing and crusting over
  • Rash (may begin as a single spot, but if person scratches it, it may spread to other areas).
  • In infants, a single or possibly multiple blisters filled with pus, easy to pop and – when broken – leave a reddish raw-looking base.
  • Lymphadenopathy – local lymph nodes near the infection may be swollen.

Treatment of Impetigo

All but the most complicated case of impetigo are treated on an outpatient basis.

Treatment itself generally consists of a topical antibiotics, for example Bactroban or Altabax.

While oral antibiotics used includes the cephalexin class of antibiotics (Keflex), Amoxicillin and clavulanate (Augmentin); Dicloacillin (Dycil, Dynapen) and less commonly now erythromycin.

Uncomplicated case generally respond rapidly to antibiotic therapy.

See also:

NVC-422 topical gel for the treatment of impetigo

Susan M Iovino,1 Kenneth D Krantz,1 Daisy M Blanco,2 Josefina A Fernández,3 Naomi Ocampo,1 Azar Najafi,1 Bahram Memarzadeh,1 Chris Celeri,1 Dmitri Debabov,1 Behzad Khosrovi,1 and Mark Anderson1 1NovaBay Pharmaceuticals Inc., Emeryville, CA, USA 2Instituto Dermatológico, Santo Domingo, Dominican Republic 3Robert Reid Cabral Children's Hospital, Santo Domingo, Dominican Republic Address correspondence to: Dr. Mark B. Anderson, NovaBay Pharmaceuticals, Inc. 5980 Horton St # 550 Emeryville Ca. 94608 Tel: 510-219-5188 E-mail: manderson@novabaypharma.com

Received June 8, 2011; Accepted July 19, 2011.

Abstract

Impetigo is a highly contagious bacterial skin infection affecting children worldwide that is caused by the Gram-positive bacteria Staphylococcus aureus, Streptococcus pyogenes, or both. Staphylococcus species can quickly develop drug resistance rendering mupirocin, fusidic acid, and erythromycin ineffective. Preclinical and clinical studies demonstrated that NVC-422 (N, N-dichloro-2, 2-dimethyltaurine) rapidly kills pathogens without the development of drug resistance. 129 patients with clinically diagnosed impetigo were randomized to three dose groups (0.1, 0.5, or 1.5% NVC-422 topical gel) in a study conducted at 2 centers; 125 patients (97%) had microbiologically confirmed infection. Treatment was administered three times a day (TID) for 7 days to all randomized subjects. Response was measured at the completion of treatment (Day 8) and 1 week post treatment (Day 15) by the Skin Infection Rating Scale (SIRS) and by microbiological response. A total of 120 subjects (96%) completed all 7 days of treatment and were assessed at end of treatment (EOT). Clinical response rate at EOT in the PPC population was excellent in each of the dose groups (84.6%, 87.2%, and 92.3% in the 0.1%, 0.5% and 1.5% dose groups respectively). The majority of the infections were caused by S. aureus, alone (106/125, 85%) of which approximately 10% were MRSA. There were no clinical recurrences in any treatment groups. Treatment-emergent adverse events were seen in 5.4% of the subjects (7/129) and were mild to moderate and resolved. NVC-422 topical gel administered TID was well tolerated, with high rates of clinical and microbiological responses for treating impetigo.

Keywords: Impetigo, NVC-422, Clinical Phase 2, Staphylococcus, Streptococcus, MRSA

See Also:

NVC-422 topical gel for the treatment of impetigo

Susan M Iovino,1 Kenneth D Krantz,1 Daisy M Blanco,2 Josefina A Fernández,3 Naomi Ocampo,1 Azar Najafi,1 Bahram Memarzadeh,1 Chris Celeri,1 Dmitri Debabov,1 Behzad Khosrovi,1 and Mark Anderson1 1NovaBay Pharmaceuticals Inc., Emeryville, CA, USA 2Instituto Dermatológico, Santo Domingo, Dominican Republic 3Robert Reid Cabral Children's Hospital, Santo Domingo, Dominican Republic Address correspondence to: Dr. Mark B. Anderson, NovaBay Pharmaceuticals, Inc. 5980 Horton St # 550 Emeryville Ca. 94608 Tel: 510-219-5188 E-mail: manderson@novabaypharma.com

Received June 8, 2011; Accepted July 19, 2011.

Abstract

Impetigo is a highly contagious bacterial skin infection affecting children worldwide that is caused by the Gram-positive bacteria Staphylococcus aureus, Streptococcus pyogenes, or both. Staphylococcus species can quickly develop drug resistance rendering mupirocin, fusidic acid, and erythromycin ineffective. Preclinical and clinical studies demonstrated that NVC-422 (N, N-dichloro-2, 2-dimethyltaurine) rapidly kills pathogens without the development of drug resistance. 129 patients with clinically diagnosed impetigo were randomized to three dose groups (0.1, 0.5, or 1.5% NVC-422 topical gel) in a study conducted at 2 centers; 125 patients (97%) had microbiologically confirmed infection. Treatment was administered three times a day (TID) for 7 days to all randomized subjects. Response was measured at the completion of treatment (Day 8) and 1 week post treatment (Day 15) by the Skin Infection Rating Scale (SIRS) and by microbiological response. A total of 120 subjects (96%) completed all 7 days of treatment and were assessed at end of treatment (EOT). Clinical response rate at EOT in the PPC population was excellent in each of the dose groups (84.6%, 87.2%, and 92.3% in the 0.1%, 0.5% and 1.5% dose groups respectively). The majority of the infections were caused by S. aureus, alone (106/125, 85%) of which approximately 10% were MRSA. There were no clinical recurrences in any treatment groups. Treatment-emergent adverse events were seen in 5.4% of the subjects (7/129) and were mild to moderate and resolved. NVC-422 topical gel administered TID was well tolerated, with high rates of clinical and microbiological responses for treating impetigo.

Keywords: Impetigo, NVC-422, Clinical Phase 2, Staphylococcus, Streptococcus, MRSA

Pub Med

Prognosis of Impetigo

Because impetigo responds rapidly to antibiotic therapy, the prognosis is excellent although it can reoccur.

Generally the lesions seldom scar, except in the most severe of cases.

Keywords

Impetigo, impetigo contagiosa, impetigo bullosa, streptococcal impetigo, staphylococcal impetigo, nonbullous impetigo, bullous impetigo, crusted tetter, pyoderma, group A beta hemolytic streptococci, GABHS

Pat

Impetigo – Medline Plus

Definition

Impetigo is a skin disorder caused by bacterial infection and characterized by crusting skin lesions.

Causes, incidence, and risk factors

Impetigo is a common skin infection. It is most common in children, particularly children in unhealthy living conditions. In adults, it may follow other skin disorders. Impetigo may follow a recent upper respiratory infection such as a cold or other viral infection. It is similar to cellulitis, but is more superficial, involving infection of the top layers of the skin with streptococcus (strep), staphylococcus (staph), or both.

The skin normally has many types of bacteria on it, but intact skin is an effective barrier that keeps bacteria from entering and growing within the body. When there is a break in the skin, bacteria can enter the body and grow there, causing inflammation and infection. Breaks in the skin may occur with insect bites, animal bites, or human bites; or other injury or trauma to the skin. Impetigo may occur on skin where there is no visible break.

Impetigo begins as an itchy, red sore that blisters, oozes and finally becomes covered with a tightly adherent crust. It tends to grow and spread. Impetigo is contagious. The infection is carried in the fluid that oozes from the blisters. Rarely, impetigo may form deeper skin ulcers.

Symptoms

Skin lesion on the face/ lips, or on the arms or legs, spreading to other areas. Typically this lesion begins as a cluster of tiny blisters which burst, followed by oozing and the formation of a thick honey or brown colored crust that is firmly stuck to the skin.

Itching blister:

  • Filled with yellow or honey-colored fluid
  • Oozing and crusting over

Rash (may begin as a single spot, but if child digs at it, it may spread to other areas).

In infants, a single or possibly multiple blisters filled with pus, easy to pop and when broken leave a reddish raw-looking base.

Lymphadenopathy – local lymph nodes near the infection may be swollen.

Signs and tests

Diagnosis is based primarily on the appearance of the skin lesion. A culture of the skin or mucosal lesion usually grows streptococcus or staphylococcus.

Treatment

The goal is to cure the infection and relieve the symptoms.

A mild infection is typically treated with a prescription antibacterial cream such as Bactroban. Oral antibiotics (such as erythromycin or dicloxacillin) are also frequently prescribed and result in rapid clearing of the lesions.

Wash the skin several times a day, preferably with an antibacterial soap, to remove crusts and drainage.

Prevent the spread of infection

Use a clean washcloth and towel each time. Do not share towels, clothing, razors, and so on with other family members. Wash the hands thoroughly after touching the skin lesions.

Expectations (prognosis)

The sores of impetigo heal slowly and seldom scar. The cure rate is extremely high, but they often come back in young children.

Complications

  • The infection could spread to other parts of the body. This is common.
  • Children often have multiple patches of impetigo.
  • A systemic infection could lead to kidney failure (post-streptococcal glomerulonephritis). This is a rare occurrence.
  • Permanent skin damage and scarring (also extremely rare).

Prevention

Good general health and hygiene help to prevent infection. Minor abrasions or areas of damaged skin should be thoroughly cleansed with soap and clean water. A mild antibacterial agent may be applied if desired.

Impetigo is contagious, so avoid skin contact with drainage from impetigo lesions.

Update Date: 4/15/2003

Medline Plus

Spread of the epidemic European fusidic acid-resistant impetigo clone (EEFIC) in general practice patients in the south of The Netherlands.

Jan 2012

Rijnders MI, Wolffs PF, Hopstaken RM, den Heyer M, Bruggeman CA, Stobberingh EE.

Source

Department of Medical Microbiology, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands.

Abstract

OBJECTIVES: We evaluated the susceptibility to fusidic acid, mupirocin and retapamulin of Staphylococcus aureus isolated from nasal and wound swabs.

METHODS: The susceptibility to the three agents of S. aureus isolated from general patients in the south of The Netherlands with a skin or soft tissue infection was determined between January 2007 and December 2008. Fusidic acid-resistant isolates were tested for the presence of fusidic acid-resistant genes and compared with the epidemic European fusidic acid-resistant impetigo clone (EEFIC).

RESULTS: Fusidic acid resistance was found in 23% of the nasal and 35% of the wound isolates, the majority (∼90%) being fusB positive. Most of the isolates belonged to spa type t171 and were isolated from younger patients. One isolate was retapamulin resistant (MIC 8 mg/L) and two were mupirocin resistant.

CONCLUSIONS: The EEFIC clone was relatively highly prevalent among the isolated S. aureus. The usefulness of fusidic acid as first-line agent for the treatment of impetigo is questionable. As mupirocin is used in The Netherlands for eradication of methicillin-resistant S. aureus, it is not an alternative; retapamulin might be useful, but further in vivo studies are warranted.

PubMed

A case of recurrent impetigo herpetiformis treated with systemic corticosteroids and narrowband UVB.

Jan. 2012

Bozdag K, Ozturk S, Ermete M.

Source

Department of Dermatology.

Abstract

Keywords Impetigo herpetiformis, narrowband ultraviolet B, pregnancy

Impetigo herpetiformis is a rare pustular eruption with usual onset during the third trimester of pregnancy. The disease tends to remit after delivery, but may recur in subsequent pregnancies. Here we present a recurrent case of impetigo herpetiformis with earlier onset and poor response to corticosteroids in the subsequent pregnancy. She had widespread, erythematosquamous patches with tiny superficial pustules in the third trimester of her first pregnancy. Histopathological and clinical findings were consistent with impetigo herpetiformis. She was treated with systemic prednisolone and had a healthy baby without any complication. Three years later, the patient presented with impetigo herpetiformis again in the second trimester of her second pregnancy. After six weeks of oral prednisolone treatment, the lesions improved, but there were still new pustule formations and narrowband ultraviolet B treatment was added. Skin eruption cleared and she had a healthy baby in the 38th week of her second pregnancy. The corticosteroid dose was tapered gradually and stopped after delivery. Early diagnosis and treatment is crucial in impetigo herpetiformis because of the risk of maternal and fetal complications. When prednisolone is not enough to control the eruption alone, narrowband UVB can safely be added to the treatment.

Informa

Interventions for impetigo.

Jan. 2012

Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LW, Morris AD, Butler CC, Berger M, van der Wouden JC.

Source

Department of General Practice, Erasmus Medical Center, PO Box 2040, Rotterdam, Netherlands, 3000 CA.

Abstract

BACKGROUND: Impetigo is a common, superficial bacterial skin infection, which is most frequently encountered in children. There is no generally agreed standard therapy, and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants. This is an updated version of the original review published in 2003.

OBJECTIVES: To assess the effects of treatments for impetigo, including non-pharmacological interventions and 'waiting for natural resolution'.

SEARCH METHODS: We updated our searches of the following databases to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 2005), EMBASE (from 2007), and LILACS (from 1982). We also searched online trials registries for ongoing trials, and we handsearched the reference lists of new studies found in the updated search.

SELECTION CRITERIA: Randomised controlled trials of treatments for non-bullous, bullous, primary, and secondary impetigo. DATA COLLECTION AND ANALYSIS: Two independent authors undertook all steps in data collection. We performed quality assessments and data collection in two separate stages.

MAIN RESULTS: We included 57 trials in the first version of this review. For this update 1 of those trials was excluded and 12 new trials were added. The total number of included trials was, thus, 68, with 5578 participants, reporting on 50 different treatments, including placebo. Most trials were in primary impetigo or did not specify this.For many of the items that were assessed for risk of bias, most studies did not provide enough information. Fifteen studies reported blinding of participants and outcome assessors.Topical antibiotic treatment showed better cure rates than placebo (pooled risk ratio (RR) 2. 24, 95% confidence interval (CI) 1.61 to 3.13) in 6 studies with 575 participants. In 4 studies with 440 participants, there was no clear evidence that either of the most commonly studied topical antibiotics (mupirocin and fusidic acid) was more effective than the other (RR 1.03, 95% CI 0.95 to 1.11).In 10 studies with 581 participants, topical mupirocin was shown to be slightly superior to oral erythromycin (pooled RR 1.07, 95% CI 1.01 to 1.13). There were no significant differences in cure rates from treatment with topical versus other oral antibiotics. There were, however, differences in the outcome from treatment with different oral antibiotics: penicillin was inferior to erythromycin, in 2 studies with 79 participants (pooled RR 1.29, 95% CI 1.07 to 1.56), and cloxacillin, in 2 studies with 166 participants (pooled RR 1.59, 95% CI 1.21 to 2.08).There was a lack of evidence for the benefit of using disinfectant solutions. When 2 studies with 292 participants were pooled, topical antibiotics were significantly better than disinfecting treatments (RR 1.15, 95% CI 1.01 to 1.32).The reported number of side-effects was low, and most of these were mild. Side-effects were more common for oral antibiotic treatment compared to topical treatment. Gastrointestinal effects accounted for most of the difference.Worldwide, bacteria causing impetigo show growing resistance rates for commonly used antibiotics. For a newly developed topical treatment, retapamulin, no resistance has yet been reported.

AUTHORS' CONCLUSIONS: There is good evidence that topical mupirocin and topical fusidic acid are equally, or more, effective than oral treatment. Due to the lack of studies in people with extensive impetigo, it is unclear if oral antibiotics are superior to topical antibiotics in this group. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. There is a lack of evidence to support disinfection measures to manage impetigo.

Cochrane Library

Prevalence of Staphylococcus aureus toxins and nasal carriage in furuncles and impetigo

Br J Dermatol. 2007 Dec

Durupt F, Mayor L, Bes M, Reverdy ME, Vandenesch F, Thomas L, Etienne J. INSERM, U851, 69008 Lyon, France; Université Lyon 1, Centre National de Référence des Staphylocoques, Faculté Laennec, 69008 Lyon, France, and Service de Dermatologie, Hôtel Dieu & Université Lyon 1, 69288 Lyon cedex 02, France.

Background The precise role of Staphylococcus aureus toxins and nasal carriage in common skin infections remains unclear.

Objectives To seek correlations between toxin expression, S. aureus nasal carriage and clinical manifestations in patients with community-acquired furuncles and impetigo.

Methods From November 2004 to August 2005, we studied clinical data and bacteriological samples prospectively collected from 121 patients presenting with furuncles or impetigo.

Results Sixty-four patients (31 with furuncles and 33 with impetigo) had S. aureus-positive skin culture. Panton-Valentine leukocidin (PVL) genes were present in 13 of 31 (42%) isolates from furuncles and were associated with epidemic furunculosis. Exfoliative toxin genes were present in 10 of 10 (100%) and 12 of 21 (57%) bullous and nonbullous impetigo isolates, respectively. Nasal carriage of S. aureus was found in 58% of patients overall. It was strongly associated with chronic furunculosis but not with simple furuncles (88% vs. 29%, P < 0.007). Skin and nose isolates from a given patient always had identical characteristics. Methicillin-resistant S. aureus accounted for four of 64 (6%) positive skin cultures.

Conclusions PVL is not involved in all types of furuncles but is associated with epidemic furunculosis. Both bullous and nonbullous forms of impetigo are associated with exfoliative toxins. Staphylococcus aureus nasal carriage is associated with the chronicity of furuncles.

PMID: 17916211 PubMed - in process]

Impetigo in epidemic and nonepidemic phases: an incidence study over 4(1/2) years in a general population

Br J Dermatol. 2007

Rørtveit S, Rortveit G. Municipal Health Services of Austevoll Kommune, 5399 Bekkjarvik, Norway.sverre.rortveit@aknett.net

BACKGROUND: Little is known about incidence and natural variation of impetigo in general populations.

OBJECTIVES: To investigate the natural course of impetigo in a well-defined population, and to study the resistance pattern of the causal bacteria over time.

METHODS: This is a population-based incidence study in Austevoll, an island community of 4457 inhabitants in Norway, in the years 2001-2005. Incidence rates are given as events per person-year. Epidemic periods were identified by statistical process-control analyses.

RESULTS: The incidence rate of impetigo for the whole study period was 0.017 events per person-year, corresponding to a total of 334 cases. The incidence rates were 0.009, 0.026, 0.019, 0.016 and 0.009 in the years 2001, 2002, 2003, 2004 and 2005, respectively. Three epidemics were identified, starting in August of 2002, 2003 and 2004, lasting for 11, 11 and 5 weeks, respectively. Incidence rates in these epidemic periods were 0.099, 0.045 and 0.074, respectively. In epidemic periods, Staphylococcus aureus was the causal bacterium in 89% (117/132) of cases, while this proportion was 68% (84/123) in nonepidemic periods (P < 0.01). Staphylococcus aureus was resistant to fusidic acid in 84% (98/117) and 64% (54/84) of impetigo cases in epidemic and nonepidemic periods, respectively (P < 0.01). When investigating all types of infections caused by S. aureus in the study period, the proportion of fusidic acid resistance in impetigo cases (152/201, 76%) differed significantly from fusidic acid resistance in other infections (18/116, 16%) (P < 0.01).

CONCLUSIONS: Distinctive epidemic outbreaks occurred during the summer of three of the five follow-up years. In outbreaks, S. aureus was more frequently the causal agent and the sensitivity to fusidic acid decreased significantly.

PMID: 17553056 PubMed - indexed for MEDLINE]

External Links

Impetigo Information

NIH

Effect of Antenatal Zinc Supplementation on Impetigo in Infants in Bangladesh.

Impetigo Skinsite.com

Impetigo DermNet NZ

Impetigo E Medicine

Impetigo E Medicine 2

eMedicine (1)

Impetigo Netdoctorco.uk

Impetigo Fact Sheet

Impetigo Compendium of Images – Dermatlas

Treating impetigo in primary care.

NIH

Diagnosis and treatment of impetigo

American Family Physicians

AAFP

Diagnostic Codes

ICD 9

ICD-9-CM Diagnosis 684

Impetigo

A common superficial bacterial infection caused by STAPHYLOCOCCUS AUREUS or group A beta-hemolytic streptococci.

Characteristics include pustular lesions that rupture and discharge a thin, amber-colored fluid that dries and forms a crust. This condition is commonly located on the face, especially about the mouth and nose.

684 is a specific code that can be used to specify a diagnosis

684 contains 14 index entries

Other Infections ICD 9 Diagnostic Codes

  • 680 Carbuncle and furuncle
  • 681 Cellulitis and abscess of finger and toe
  • 682 Other cellulitis and abscess
  • 683 Acute lymphadenitis
  • 684 Impetigo
  • 685 Pilonidal cyst
  • 686 Other local infections of skin and subcutaneous tissue

ICD 10

L01 - Impetigo

Excludes: impetigo herpetiformis ( L40.1 ) pemphigus neonatorum ( L00 )

L01.0 - Impetigo [any organism] [any site]

Bockhart's impetigo

L01.1 - Impetiginization of other dermatoses

Diagnostic Images

Lymphedema People Internal Links

Lymphedema People Resources

impetigo.txt · Last modified: 2012/10/16 14:40 (external edit)