今日の臨床サポート

伝染性膿痂疹

著者: 上蓑義典 慶應義塾大学医学部 臨床検査医学

監修: 上原由紀 聖路加国際病院 臨床検査科/感染症科

著者校正/監修レビュー済:2021/07/07
患者向け説明資料

概要・推奨   

  1. 膿痂疹に対し外用抗菌薬を使用することは強く推奨される(推奨度1)
  1. 外用薬としてムピロシンまたはフシジン酸の使用推奨される(推奨度1)
  1. 膿や滲出液のおよびグラム染色起炎菌同定のため可能であれば推奨される(推奨度2
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
上蓑義典 : 特に申告事項無し[2021年]
監修:上原由紀 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 培養およびグラム染色の有用性に関する推奨を変更した。

病態、疫学、診察

疾患情報  
  1. 伝染性膿痂疹とは、黄色ブドウ球菌または連鎖球菌が皮膚の浅層に感染し、水疱あるいは膿疱を来す皮膚の化膿性疾患である。膿痂疹の診断は、皮膚所見から臨床的になされる。
  1. 膿痂疹には非水疱性と水疱性の2種類がある。
 
非水疱性膿痂疹

口唇周囲や鼻唇溝周囲に認められるような小丘疹から始まり、右口角に認められるような周囲に紅斑を伴う小水疱を形成し、さらにその後、左口角に認められるような黄色痂皮を形成する。

出典

img1:  Clinical Dermatology(5th Edition)
 
 
 
水疱性膿痂疹

小水疱を形成した後、画像中に2カ所存在するような弛緩性水疱を形成する。その後は、それが破綻し画像中に認められる茶色痂皮を伴う病変となる。

出典

img1:  Clinical Dermatology(5th Edition)
 
 
 
  1. 非水疱性膿痂疹は丘疹から始まり、その後、周囲に紅斑を伴う小水疱を形成し、さらにその後、表面に黄色の痂皮を形成する。
  1. 水疱性膿痂疹では小水疱が形成され、その後、黄色の漿液を内包する弛緩性水疱が形成される。それが破綻すると茶色の薄い痂皮が形成される。
  1. 接触皮膚炎との鑑別が問題となるが、膿痂疹では発疹に痛みがあることが特徴となる。
  1. 細菌学的検査は起炎菌の推定に有用である。
 
問診・診察のポイント  
  1. 周囲の膿痂疹罹患者の存在を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

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文献 

著者: Dennis L Stevens, Alan L Bisno, Henry F Chambers, E Dale Everett, Patchen Dellinger, Ellie J C Goldstein, Sherwood L Gorbach, Jan V Hirschmann, Edward L Kaplan, Jose G Montoya, James C Wade, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1086/497143. Epub 2005 Oct 14.
Abstract/Text
PMID 16231249  Clin Infect Dis. 2005 Nov 15;41(10):1373-406. doi: 10.1・・・
著者: Sander Koning, Renske van der Sande, Arianne P Verhagen, Lisette W A van Suijlekom-Smit, Andrew D Morris, Christopher C Butler, Marjolein Berger, Johannes C van der Wouden
雑誌名: Cochrane Database Syst Rev. 2012 Jan 18;1:CD003261. doi: 10.1002/14651858.CD003261.pub3. Epub 2012 Jan 18.
Abstract/Text 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.

PMID 22258953  Cochrane Database Syst Rev. 2012 Jan 18;1:CD003261. doi・・・
著者: Ajay George, Greg Rubin
雑誌名: Br J Gen Pract. 2003 Jun;53(491):480-7.
Abstract/Text BACKGROUND: Impetigo is a common clinical problem seen in general practice. Uncertainty exists as to the most effective treatment, or indeed if treatment is necessary.
AIM: To determine the most effective treatment for impetigo in a systemically well patient.
DESIGN OF STUDY: Systematic review and meta-analysis.
METHOD: Databases were searched for relevant studies. The Cochrane highly sensitive randomised controlled trial (RCT) search string was employed and combined with the word 'impetigo' as the MeSH term and keyword. The bibliographies of relevant articles were searched for additional references. RCTs that were either double- or observer-blind, and involved systemically well patients of any age in either primary or secondary care settings, were included. Studies that selected patients on the basis of skin swab results were excluded, as were studies that were not in English. Cure or improvement of impetigo reported at seven to 14 days from start of treatment was the primary outcome measure. Meta-analysis was performed on homogeneous studies.
RESULTS: Three hundred and fifty-nine studies were identified, of which 16 met the inclusion criteria. Meta-analysis demonstrated that topical antibiotics are more effective than placebo (odds ratio [OR] = 2.69, 95% confidence interval [CI] = 1.49 to 4.86). There is weak evidence for the superiority of topical antibiotics over some oral antibiotics, such as erythromycin (OR = 0.48, 95% CI = 0.23 to 1.00). There is no significant difference between the effects of mupirocin and fusidic acid (OR = 1.76, 95% CI = 0.77 to 4.03).
CONCLUSION: This review found limited high-quality evidence to inform the treatment of impetigo. From that which is available, we would recommend the use of a topical antibiotic for a period of seven days in a systemically well patient with limited disease. Further research is needed on the role of flucloxacillin and non-antibiotic treatments for impetigo.

PMID 12939895  Br J Gen Pract. 2003 Jun;53(491):480-7.
著者: Stephen P Luby, Mubina Agboatwalla, Daniel R Feikin, John Painter, Ward Billhimer, Arshad Altaf, Robert M Hoekstra
雑誌名: Lancet. 2005 Jul 16-22;366(9481):225-33. doi: 10.1016/S0140-6736(05)66912-7.
Abstract/Text BACKGROUND: More than 3.5 million children aged less than 5 years die from diarrhoea and acute lower respiratory-tract infection every year. We undertook a randomised controlled trial to assess the effect of handwashing promotion with soap on the incidence of acute respiratory infection, impetigo, and diarrhoea.
METHODS: In adjoining squatter settlements in Karachi, Pakistan, we randomly assigned 25 neighbourhoods to handwashing promotion; 11 neighbourhoods (306 households) were randomised as controls. In neighbourhoods with handwashing promotion, 300 households each were assigned to antibacterial soap containing 1.2% triclocarban and to plain soap. Fieldworkers visited households weekly for 1 year to encourage handwashing by residents in soap households and to record symptoms in all households. Primary study outcomes were diarrhoea, impetigo, and acute respiratory-tract infections (ie, the number of new episodes of illness per person-weeks at risk). Pneumonia was defined according to the WHO clinical case definition. Analysis was by intention to treat.
FINDINGS: Children younger than 5 years in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than controls (95% CI (-65% to -34%). Also compared with controls, children younger than 15 years in households with plain soap had a 53% lower incidence of diarrhoea (-65% to -41%) and a 34% lower incidence of impetigo (-52% to -16%). Incidence of disease did not differ significantly between households given plain soap compared with those given antibacterial soap.
INTERPRETATION: Handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhoea and acute lower respiratory infections. Handwashing with daily bathing also prevents impetigo.

PMID 16023513  Lancet. 2005 Jul 16-22;366(9481):225-33. doi: 10.1016/S・・・

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