tag:theconversation.com,2011:/uk/topics/impetigo-33150/articlesImpetigo – The Conversation2023-01-16T23:36:08Ztag:theconversation.com,2011:article/1976172023-01-16T23:36:08Z2023-01-16T23:36:08ZStrep A cases are rising. We must remember our earliest hygiene lessons as vaccine trials continue<figure><img src="https://images.theconversation.com/files/504594/original/file-20230116-19027-w9fwaw.jpg?ixlib=rb-1.1.0&rect=38%2C66%2C6298%2C4151&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cute-likable-mixed-race-teen-600w-1974397403.jpg">Shutterstock</a></span></figcaption></figure><p>Group A streptococci, also known as “strep A”, were the first organisms ever identified to be the cause of a disease. </p>
<p>In the mid-1800s, Hungarian physician <a href="https://www.pbs.org/newshour/health/ignaz-semmelweis-doctor-prescribed-hand-washing">Ignaz Semmelweis</a> first noted the link between a lack of hygienic practices – such as handwashing – among medical staff and puerperal (or childbirth) fever. Louis Pasteur subsequently <a href="https://www.ncbi.nlm.nih.gov/books/NBK333430/">demonstrated</a> that it was caused by the microbe we now refer to as strep A. </p>
<p>Puerperal fever, a life-threatening condition, is much less common now, but strep A has not gone away. In fact, it is known to cause more types of disease than any other single micro-organism. </p>
<p>And infections appear to be <a href="https://www.abc.net.au/news/2023-01-17/group-a-streptococcal-explainer-cases-in-australia/101854070">on the rise</a>.</p>
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<h2>A common organism that can cause everyday and rare illnesses</h2>
<p>Strep A organisms commonly live on people and, while they don’t usually cause disease, they can become virulent. Their propensity to cause illness depends on the strain of the organism, the simultaneous presence of other microbes (often viruses), and the level of immunity the person may already have. </p>
<p>The most common diseases <a href="https://www.cdc.gov/groupastrep/diseases-public/index.html">caused by strep A</a> are tonsillitis (also called “strep throat”) and impetigo (also known as “school sores”). </p>
<p>These conditions are relatively benign, but if untreated can give rise in some individuals to deadly complications, including “invasive” strep A disease and <a href="https://www.who.int/news-room/fact-sheets/detail/rheumatic-heart-disease#:%7E:text=The%20disease%20results%20from%20damage,death%20or%20life%2Dlong%20disability.">rheumatic heart disease</a>, which is the most commonly acquired heart disease in people younger than 25. </p>
<p>Other conditions caused by strep A include erysipelas and cellulitis (infections of the skin), glomerulonephritis (inflammation of the kidneys), <a href="https://www.cdc.gov/groupastrep/diseases-public/scarlet-fever.html">scarlet fever</a> (named for the red rash it causes) and <a href="https://www.cdc.gov/groupastrep/diseases-public/streptococcal-toxic-shock-syndrome.html">toxic shock syndrome</a> (which can cause organ failure and death).</p>
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Read more:
<a href="https://theconversation.com/strep-a-three-doctors-explain-what-you-need-to-look-out-for-195972">Strep A: three doctors explain what you need to look out for</a>
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<h2>Rising cases in children</h2>
<p>Recently, there is concern because case numbers of invasive streptococcal disease (now a <a href="https://nindss.health.gov.au/pbi-dashboard/">notifiable disease</a> in Australia) are <a href="https://www.theage.com.au/national/victoria/two-children-die-amid-marked-increase-in-invasive-strep-a-infections-20230103-p5ca0e.html">rising</a>, particularly among children. </p>
<p>Invasive disease occurs when an otherwise simple infection of the tonsils or skin spreads beyond the local tissue and invades deep tissue. From there it can spread to distant sites in the body, leading to shock, potential loss of limbs, and death. </p>
<p>Although cases are <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON429">on the rise</a> in multiple countries, the chances of an individual case of strep throat progressing to invasive disease are low. Worldwide there is an <a href="https://pubmed.ncbi.nlm.nih.gov/16253886/">estimated incidence</a> of around 700 million cases of tonsillitis or school sores every year, of which about 1 in 1,000 lead to invasive disease.</p>
<p>The reason for the recent jump in case numbers of invasive disease is unclear. </p>
<p>A new strain may be responsible but this needs more investigation. We know there are <a href="https://pubmed.ncbi.nlm.nih.gov/23464795/">hundreds of strains</a> of strep A.</p>
<p>In the United Kingdom, which has also seen a <a href="https://www.gov.uk/government/publications/group-a-streptococcal-infections-activity-during-the-2022-to-2023-season/group-a-streptococcal-infections-first-update-on-seasonal-activity-in-england-2022-to-2023">significant rise</a> in cases, a few strains seem to dominate. But these same strains have been circulating in the community for several years. </p>
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<span class="caption">Young children and older people are the ones most at risk of Strep A complications.</span>
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Read more:
<a href="https://theconversation.com/what-are-school-sores-and-how-do-you-get-rid-of-them-86930">What are school sores and how do you get rid of them?</a>
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<h2>Is it because of lockdowns?</h2>
<p>It seems likely, both in the UK and here, that the main reason we are seeing more cases now is because we are experiencing more respiratory infections across the board as we come out of COVID-imposed isolation, especially from influenza. </p>
<p>Co-infection with influenza and strep A can render <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800185/">both infections</a> significantly more dangerous and difficult to control.</p>
<p>I am not aware of data showing invasive strep A cases are occurring more in people also infected with SARS-CoV-2 (the virus that causes COVID), but this requires investigation also.</p>
<p>Should we be alarmed? We are rightly nervous when we see a sudden jump in any serious infectious disease, but early indications are that the rates of invasive disease are similar to pre-pandemic rates.</p>
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<h2>Old lessons and future protections</h2>
<p>The population groups most at risk are those under ten years or over 65 years of age. People with chronic conditions such as diabetes, cancer or who are immunosuppressed are also less able to fight off infection. These groups and those who care for them need to be more vigilant. </p>
<p><a href="https://www.health.vic.gov.au/health-advisories/health-warning-on-invasive-group-a-streptococcal-disease">Warning signs</a> are a sore throat and high fever, especially if combined with a skin rash (scarlet fever), severe pain from an infected skin sore, and any difficulties with breathing. Prompt medical attention is required for any of these symptoms.</p>
<p>Hygiene practices are also important for prevention. Strep A is highly contagious and as such we should adhere to the habits we all learnt during the pandemic – washing hands frequently, coughing or sneezing into a tissue and staying home if symptomatic. These measures will limit spread and are no less important now than they were when Semmelweis first proposed them in 1847.</p>
<p>In the long term, a vaccine to prevent strep A infection would completely prevent invasive strep A disease and rheumatic heart disease. </p>
<p>A few groups worldwide are developing strep A vaccines. <a href="https://news.griffith.edu.au/2021/02/24/potential-vaccine-to-prevent-deadly-strep-a-infection/">Our group</a> has one that is undergoing a <a href="https://theconversation.com/vaccine-for-strep-throat-and-rheumatic-fever-to-be-trialled-in-humans-63390">clinical trial</a> in Alberta, Canada. The vaccine was developed at Griffith University and is aimed at preventing infection of the throat or skin from all strains of strep A. </p>
<p>If it does this, it will also prevent invasive strep A disease and rheumatic heart disease. Globally, that could save as many as 500,000 lives each year.</p>
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Read more:
<a href="https://theconversation.com/vaccine-for-strep-throat-and-rheumatic-fever-to-be-trialled-in-humans-63390">Vaccine for strep throat and rheumatic fever to be trialled in humans</a>
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<p class="fine-print"><em><span>Michael Good works for Griffith University He receives grant funding from NHMRC, the Snow Foundation, the Li Ka Shing Institute (University of Alberta), the Lowitja Institute and the Heart Foundation.</span></em></p>Strep A is a common infection that can give you a passing sore throat or something much more serious. Cases seems to be rising around the world.Michael Good, Professor and NHMRC Investigator Fellow, Institute for Glycomics, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/869302018-02-01T17:57:00Z2018-02-01T17:57:00ZWhat are school sores and how do you get rid of them?<figure><img src="https://images.theconversation.com/files/203007/original/file-20180123-182965-1180o5w.jpg?ixlib=rb-1.1.0&rect=0%2C1334%2C3538%2C1528&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The usual culprit is the bacterium _Staphylococcus aureus_, better known as “golden staph”.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/698395990?src=5oGzvQ_ZB3yKGJB3Xjhv3g-2-30&size=huge_jpg">Shutterstock</a></span></figcaption></figure><p>Impetigo, or “school sores”, is a contagious infection of the very top layer of skin. It’s <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0136789">most common</a> in children aged two to six, and ends up spreading from child to child in schools and daycare centres, but can affect children and adults of all ages. </p>
<p>The good news is that it’s unlikely to cause serious harm. It usually clears up within a few weeks, without any scarring. </p>
<p>The usual culprit is the bacterium <em>Staphylococcus aureus</em>, better known as “golden staph”. <em>S. aureus</em> can cause serious infections, and has a fearsome reputation. But the bacteria <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/staphylococcus-aureus-golden-staph">commonly lives on skin</a>, lurking in the groin and nostrils without causing problems.</p>
<p>A second type of bacteria that causes impetigo is <em>Streptococcus pyogenes</em>, commonly known as “strep”. <em>S. pyogenes</em> can cause other infections such as tonsillitis and pharyngitis. In fact, it is often the “strep” responsible for “strep throat”. </p>
<p>Strep impetigo is more prevalent in rural and remote communities. It is also more common in institutional settings such as aged care facilities, boarding schools, and prisons.</p>
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Read more:
<a href="https://theconversation.com/why-simple-school-sores-often-lead-to-heart-and-kidney-disease-in-indigenous-children-86066">Why simple school sores often lead to heart and kidney disease in Indigenous children</a>
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<p>Impetigo <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/impetigo-school-sores">appears on the skin</a> one to three days after being infected by staph, or four to ten days after catching strep. It can occur on sores from scratches, insect bites and eczema, or on healthy skin. </p>
<p>The sores begin as red areas, or crops of small blisters, most commonly around the nose and mouth, and on the arms and legs. The sores then burst and begin to weep, before drying with a golden-coloured scab, often referred to as a “honey-crust”.</p>
<h2>Treatment</h2>
<p>While impetigo is unlikely to cause problems in healthy people, it’s important to <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Impetigo_school_sores/">see a GP for an accurate diagnosis</a>.</p>
<p>If only a small crop of sores is present, frequent washing with soap and water might be all that is needed. A prescription antibiotic ointment can also be used. </p>
<p>If the sores are more widespread, or there is evidence of infection spreading into the deeper skin (cellulitis), oral antibiotics are often necessary.</p>
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Read more:
<a href="https://theconversation.com/when-should-you-take-antibiotics-42751">When should you take antibiotics?</a>
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<p>Parents can speed up the healing process by removing the crusts two to three times a day. This is done by soaking the skin in a warm bath, then wiping the scabs away gently with a clean face washer and patting dry with a fresh towel. Sores should be completely covered by waterproof bandages.</p>
<p>To prevent other family members catching the infection, don’t share any towels, face washers, clothes and bed linen, and put them on a hot wash. The infected person should use a fresh towel and washer every time they bathe, and keep their nails short. </p>
<p>Kids are generally ready to go back to school once they’ve had 24 hours of antibiotics and if the sores are covered with dressings. For children not taking antibiotics, public health authorities recommend that <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Impetigo_school_sores/">children only return to school</a> when the sores are completely healed.</p>
<h2>Complications</h2>
<p>Impetigo can occasionally lead to a further, dangerous infection. If children are feverish or lethargic, sores are spreading despite antibiotics, or you’re concerned your child looks unwell, see a doctor. </p>
<p>Newborns and babies are also at higher risk of serious complications due to their immature immune systems, and so get it checked out at the first sign of infection.</p>
<p>One possible reason for sores not improving on standard antibiotics is infection by an antibiotic-resistant bacteria. Infections due to antibiotic-resistant golden staph, MRSA (methicillin-resistant <em>Staphylococcus aureus</em>), are becoming more widespread, largely due to the widespread use of antibiotics. </p>
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Read more:
<a href="https://theconversation.com/vaccine-for-strep-throat-and-rheumatic-fever-to-be-trialled-in-humans-63390">Vaccine for strep throat and rheumatic fever to be trialled in humans</a>
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<p>An <a href="https://www.mja.com.au/journal/2017/207/9/increasing-importance-community-acquired-methicillin-resistant-staphylococcus">Australian study</a> in the Hunter area of New South Wales looked at all staph infections diagnosed in the region from 2008 to 2014. Nearly 20% were drug-resistant strains. </p>
<p>For most children, though, the infection is mild and fleeting. Keep an eye on the sores, and see your GP for a diagnosis, but try not to worry if it’s a standard case. </p>
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<p><em>Dr Kristen Ochs, a GP registrar at the academic General Practice Unit, Fairfield Hospital and Ingham Institute of Applied Medical Research, co-wrote this article.</em></p><img src="https://counter.theconversation.com/content/86930/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Tam does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>School sores usually clear up within a few weeks, without any scarring. Here’s what to do if you suspect your child has them.Michael Tam, General Practitioner, and Senior Lecturer, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/860662017-12-11T01:49:16Z2017-12-11T01:49:16ZWhy simple school sores often lead to heart and kidney disease in Indigenous children<figure><img src="https://images.theconversation.com/files/195398/original/file-20171120-18528-ltzud6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Impetigo happens when itching causes the skin to break and let in disease-causing bacteria.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Impetigo, also known as school sores, is a highly contagious bacterial skin infection that occurs in children far more frequently than adults. It is one of the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">most common bacterial infections</a> in children aged two to five years. Impetigo happens when a break in the skin, from scratching an insect bite for instance, lets in disease-causing bacteria.</p>
<p>The bacteria responsible for impetigo are <em>Staphylococcus aureus</em> (<em>S. aureus</em> or staph) and <em>Streptococcus pyogenes</em> (<em>S. pyogenes</em> or group A strep). People with diabetes or other conditions that may affect the immune system, such as HIV infection, and those on medications that suppress immunity, are more susceptible.</p>
<p>While the infection itself is treatable, if left untreated it can lead to more serious conditions such as <a href="https://www.healthdirect.gov.au/cellulitis">cellulitis</a> (infection of the inner layers of skin) or <a href="https://www.healthdirect.gov.au/abscesses">abscess</a> (painful collections of pus that build up under the skin). It can also progress to kidney disease, or it could <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0000467">cause acute rheumatic fever</a>, which can affect the heart, joints, brain or skin.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-is-chronic-kidney-disease-and-why-are-one-in-three-at-risk-of-this-silent-killer-81942">Explainer: what is chronic kidney disease and why are one in three at risk of this silent killer?</a>
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<p>Around 162 million children worldwide <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">suffer from impetigo</a> at any one time. They mostly live in resource-poor tropical countries or underprivileged populations in developed countries. In Australia, about 15,000 Indigenous children are <a href="https://www.ncbi.nlm.nih.gov/pubmed/26317533">estimated to suffer</a> from impetigo – representing 40% of children in Indigenous communities.</p>
<h2>Causes and symptoms</h2>
<p>Impetigo can occur on top of other skin conditions, particularly itchy ones like eczema, scabies, insect bites, and head lice. Scratching the skin can break it and let the disease-causing bacteria in. A sore can be infectious for as long as it is weeping fluid, as the fluid and crusts of the sore contain infectious bacteria. </p>
<p>The time between becoming infected and developing symptoms is around four to ten days. Contact with the sore, or with things that have been in contact with the sore, can spread the infection to other people. </p>
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Read more:
<a href="https://theconversation.com/health-check-how-do-you-catch-and-get-rid-of-head-lice-43699">Health Check: how do you catch – and get rid of – head lice?</a>
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<p>There are two forms of impetigo: non-bullous and bullous. Non-bullous, also known as the crusted form of impetigo, accounts for about 70% of all cases and can be <a href="http://www.aafp.org/afp/2014/0815/p229.html">caused by both</a> <em>S. aureus</em> and <em>S. pyogenes</em>. It has a thick, soft, yellow crust below which is often a wet, red area. </p>
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<a href="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198074/original/file-20171207-31525-1oenrz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Crusted forms of impetigo are the most common.</span>
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<p>Non-bullous <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1470.1994.tb00092.x/abstract">impetigo spots grow slowly</a> and are smaller than the fully grown spots of bullous, or blistering, impetigo. They are not usually painful but can be itchy. The lesions generally appear on the face and extremities, often at the location of already broken skin, such as an insect bite or eczema.</p>
<p>The bullous (blistering) form of impetigo is <a href="http://www.mdedge.com/jfponline/dsm/1310/infectious-diseases/impetigo">characterised by the formation</a> of a large, fluid-filled irritating blister under the skin. It is caused exclusively by <em>S. aureus</em> and <a href="http://www.aafp.org/afp/2014/0815/p229.html">usually occurs</a> where two skin surfaces touch or rub together, such as the armpits. </p>
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<a href="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=884&fit=crop&dpr=1 600w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=884&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=884&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1111&fit=crop&dpr=1 754w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1111&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/198075/original/file-20171207-31525-7kgfv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1111&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Blistering impetigo infections usually occur where two skin surfaces touch, like the armpits.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Impetigo.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>The blisters grow rapidly in size and number. They burst quickly and leave slightly wet or shiny areas with a brown crust at the edge. Those spots continue to grow quickly even after they break open and can be many centimetres wide. They are not usually painful but can be itchy. </p>
<h2>What are the treatments?</h2>
<p>As impetigo is highly contagious, good <a href="https://www.ncbi.nlm.nih.gov/pubmed/16253886">hygiene practices are essential</a> for stopping the spread of infection. These include washing hands with soap, washing of infected clothes and towels, and covering the sore with a sticking plaster. </p>
<p>It’s also recommended that the infected child be <a href="https://www.ncbi.nlm.nih.gov/pubmed/21976576">kept away from other children</a> and school for 24 hours after starting treatment. </p>
<p>Impetigo is generally considered a mild disease that can resolve without treatment after a few weeks. But because it can cause more serious conditions, the child should be examined by a doctor and treated with appropriate antibiotics. </p>
<p>Topical antibiotics (creams) like mupirocin are recommended for mild forms of the infection. Oral antibiotics are used in more <a href="https://www.mayoclinic.org/diseases-conditions/impetigo/symptoms-causes/syc-20352352">severe cases of impetigo</a>, such as when multiple sores are present, or when topical treatments have been ineffective. The treatment should continue until all sores are completely healed. With treatment, symptoms are likely to be improved or cleared up after seven days.</p>
<h2>What happens if it’s not treated?</h2>
<p>A possible consequence of untreated impetigo is an autoimmune kidney disease called acute post-streptococcal glomerulonephritis (APSGN). It’s not frequently seen in developed countries but one <a href="https://www.ncbi.nlm.nih.gov/pubmed/16253886">estimate suggests</a> that more than 390,000 children in less developed countries are affected, compared with about 13,000 children in more developed countries.</p>
<p>In Australia, data collected from 1991-2008 in the Northern Territory revealed that 95% of cases occurred in <a href="https://www.ncbi.nlm.nih.gov/pubmed/21976576">Indigenous Australians</a>, with 98% of affected individuals living in remote locations. The average age was seven years old, with children younger than 15 accounting for 88% of all cases. </p>
<p>Given the association between APSGN and chronic kidney disease, it is important that predisposing skin infections are treated promptly and appropriately, and the risk of transmission or recurrences is minimised. Around 97% of deaths from APSGN occur in resource-poor countries or communities.</p>
<p>Acute rheumatic fever is another potential consequence of untreated impetigo. It is an autoimmune response to an untreated group A strep infection, and repeated episodes can <a href="https://www.ncbi.nlm.nih.gov/pubmed/19962028">damage the heart</a>, leading to rheumatic heart disease. </p>
<p>Both rheumatic fever and rheumatic heart disease are preventable and generally not seen in industrialised countries. But rates of <a href="https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/rheumatic-heart-disease-and-acute-rheumatic-fever/contents/table-of-contents">rheumatic fever and rheumatic heart diseases</a> in Indigenous communities are up to 26 times those in non-Indigenous populations.</p>
<hr>
<p><strong><em><a href="https://theconversation.com/why-are-aboriginal-children-still-dying-from-rheumatic-heart-disease-63814">Why are Aboriginal children still dying from rheumatic heart disease?</a></em></strong></p>
<hr>
<p>Between 1997 and 2013, <a href="http://www.aafp.org/afp/2014/0815/p229.html">97% of patients</a> diagnosed with acute rheumatic fever in the NT were Indigenous, despite Indigenous Australians <a href="http://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/649/1/NT%20Demography%20Factsheet%202015.pdf">representing about 30%</a> of the NT population. Similarly, 94% of people diagnosed with rheumatic heart disease during this time were Indigenous, and Indigenous patients were younger than the non-Indigenous patients.</p>
<p>Poor hygiene, close living and lack of access to medical care are associated with impetigo and its related complications. Resources that help lessen these risk factors will also reduce the burden of impetigo and the diseases that can develop as a consequence.</p>
<hr>
<p><em>Dr Kavya E. Baby, a basic physician trainee with ACT health, contributed to this article.</em></p><img src="https://counter.theconversation.com/content/86066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jackson Thomas received funding from government e.g. RIRDC, ACT Gov, NSW Pharmacy Council, Goodwin aged care facilities, and consultant fee and/or grants from biotech companies</span></em></p><p class="fine-print"><em><span>Asha Bowen receives research funding from the National Health and Medical Research Council of Australia for research to reduce the burden of skin sores in remote Indigenous Australians. </span></em></p><p class="fine-print"><em><span>Erin Walker, Gregory Peterson, Julia K. Christenson, and Nathan M D'Cunha do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While school sores – or impetigo – is a treatable condition, if left untreated it can lead to much more serious illness such as kidney and heart disease.Jackson Thomas, Assistant Professor/Senior Lecturer in Pharmacy, University of CanberraErin Walker, Medical Science Research Fellow, University of CanberraGregory Peterson, Deputy Dean (Research) Faculty of Health, University of TasmaniaNathan M D'Cunha, Sessional Academic, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/681472016-11-14T19:09:55Z2016-11-14T19:09:55ZScabies: a neglected parasitic disease we already know how to treat<figure><img src="https://images.theconversation.com/files/145497/original/image-20161110-25070-1jo9pkd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children living in tropical countries and in poverty often have high rates of infection with the scabies mite. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/unicefethiopia/27422673482/in/photolist-fF6fH7-fNi2S3-bpfAWr-5cxNdy-EjhEP3-HMfhX3-H1FrRd-HjT2KB-HjT8wB-HjT1oD-H19RFJ-HMfnrd-HVZ9kT-Ho2xW9-HqYEsn-H1FqN1-Gvq5N9-HqYF6M-HjT9tr-HhvVqN-H1FsFu">UNICEF Ethiopia/flickr </a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Mites living in your skin are just the start of the problems that come with having scabies. </p>
<p>The highly infectious parasitic condition is linked with extreme itchiness, bacterial infections and kidney damage, plus debilitating social and economic consequences. </p>
<p>But we’re not addressing the problem. Although a drug of known safety and efficacy is available, scabies still affects more than 100 million people across the world who can’t break free of illness and reinfection cycles. </p>
<p>This week the <a href="http://www.ntdsupport.org/cor-ntd">Coalition for Operational Research on Neglected Tropical Diseases</a> and the <a href="http://www.controlscabies.org/news/5th-global-scabies-meeting/">International Alliance for the Control of Scabies</a> met to refocus efforts to reduce the impact of scabies across the world. </p>
<h2>Scabies: mites living in your skin</h2>
<p>Scabies is a skin disease caused by infestation with a highly infectious microscopic mite, <em>Sarcoptes scabiei</em>. Less than 1mm in size, the mite burrows into the skin, and leads to intense itching and visible sores. Sleep interruption and social stigmatisation result. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145367/original/image-20161110-26299-2ttfka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Less than 1mm long, the scabies mite burrows into the skin and creates intense itching.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/136941790@N03/22635992060/in/photolist-ffoG6C-fF6fH7-nEcjSk-oCDASr-nWoJAB-fNi2S3-bpfAWr-9Mm8AY-9MiicF-b9xbdZ-7fwayX-9MihZt-sruAYQ-6ikkq6-6hnMCL-6h4Ndc-cog1R7-cofudy-cofunj-bVvVoz-coigm7-cogyos-cQg3Ub-cU7Zad-cQSvJu-AugnPb-71RABC-dbMybJ-vmPTY9">laboratorio diagnostica ancona IZSUM/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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</figure>
<p>Intense scratching triggered by scabies infection also allows bacteria (<em>Streptococcus pyogenes</em> and <em>Staphylococcus aureus</em>) to become established in the skin. </p>
<p>Scabies is usually treated with a topical cream: in Australia, permethrin is the common choice. </p>
<p>In addition to the infected person, household contacts are often infested with scabies, and so the whole household should be treated at once. However, uptake of treatment in household members is often very low and so re-infestation is common. In settings where the prevalence is high, it is very difficult to avoid re-infestation from other community members, especially among children. </p>
<h2>Scabies is a huge global problem</h2>
<p>Scabies affects more than 100 million people worldwide. It is especially common in the Pacific region: in Fiji, half of all primary school aged children have scabies, as well as one in five adults. Up to one third of people living in remote Australian Indigenous communities are infected. </p>
<p>While scabies itself is a distressing health issue, the greatest impacts occur as a result of associated bacterial infections. <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">Scabies commonly leads</a> to impetigo (skin sores), and severe skin and soft tissue infections and sometimes even invasive bacterial infection and <a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">life-threatening toxic shock syndrome</a> can follow. </p>
<p>The body’s immune response to <em>Streptococcus pyogenes</em> bacteria can cause <a href="http://www.kidshealth.org.nz/post-streptococcal-glomerulonephritis-psgn">kidney damage</a> and possibly <a href="https://www.ncbi.nlm.nih.gov/pubmed/22327467">rheumatic heart disease</a>. </p>
<p>Scabies is therefore a cause of considerable illness and is also linked to some deaths.</p>
<h2>Scabies qualifies as a Neglected Tropical Disease</h2>
<p><a href="http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002167">Efforts are increasing</a> for scabies to be added to a list of conditions classified as Neglected Tropical Diseases. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/books/NBK62521/">Neglected Tropical Disease global movement</a> began in the early 2000s in response to the <a href="http://www.un.org/millenniumgoals/">Millennium Development Goals</a>. A Department of Neglected Tropical Diseases was soon <a href="http://www.who.int/neglected_diseases/en/">established at the World Health Organisation</a> (WHO) to coordinate and support policies and strategies specifically for the control of neglected tropical diseases.</p>
<p><a href="http://www.who.int/neglected_diseases/diseases/summary/en/">Seventeen conditions</a> currently make up the Neglected Tropical Diseases list, including <a href="http://www.who.int/onchocerciasis/en/">onchocerciasis</a> (river blindness), <a href="http://www.who.int/lymphatic_filariasis/en/">lymphatic filariasis</a> (parasitic worms in the lymph system), bacterial eye infections known as <a href="http://www.who.int/trachoma/en/">blinding trachoma</a>, <a href="http://www.who.int/schistosomiasis/en/">schistosomiasis</a> (blood parasites acquired through water) and <a href="http://www.who.int/intestinal_worms/en/">soil transmitted intestinal worms</a>. </p>
<p>Although not currently on the list, scabies has many features that warrant its inclusion. These include its high prevalence in low to middle income countries and in disadvantaged communities, the social stigma it causes, the chronic morbidity associated with the disease and known success of mass drug administration as a control strategy.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145368/original/image-20161110-26340-or08x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The skin infection impetigo develops when bacteria colonise skin damaged through intense scratching in scabies.</span>
<span class="attribution"><span class="source">Andrew Steer</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Mass drug administration for disease control</h2>
<p><a href="http://www.who.int/neglected_diseases/preventive_chemotherapy/en/">Mass drug administration</a> is the centrepiece of ambitious global plans to eliminate several major Neglected Tropical Diseases. More than 700 million people receive mass drug administration every year through large regional and global programs supported by the World Health Organization and partners. At the community level, drugs are delivered by specially trained distribution teams. </p>
<p>The oral drug <a href="http://www.merck.com/product/usa/pi_circulars/s/stromectol/stromectol_pi.pdf">ivermectin</a> is the most frequently delivered agent, used in highly successful programs for control of <a href="http://www.who.int/lymphatic_filariasis/elimination-programme/en/">lymphatic filariasis</a> and <a href="http://www.who.int/onchocerciasis/control/en/">onchocerciasis</a>. </p>
<p>The <a href="https://www.nobelprize.org/nobel_prizes/medicine/laureates/2015/press.html">2015 Nobel Prize for Medicine</a> was awarded to William Campbell and Satoshi Omura for their discovery of ivermectin and in recognition of the contribution of the drug in improving global public health. </p>
<h2>A new approach for scabies eradication</h2>
<p>Could mass drug administration for scabies work? Mass permethrin treatment for scabies was successful in <a href="https://www.ncbi.nlm.nih.gov/pubmed/1673175">Panama</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/11700814">Australia</a>. However, this cream is not ideal for use in public health initiatives because it is messy to apply and adherence can be low, and because the tubes are bulky and difficult to transport. </p>
<p>But scabies can also be killed effectively with ivermectin, an oral medication that comes in tablet form. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/26650152">clinical trial conducted in a Fijian community</a> found a single round of ivermectin mass drug administration was able to virtually eliminate scabies: prevalence was reduced from 32% to less than 2%. This reduction in scabies was associated with a 67% drop in the prevalence of scabies-linked bacterial impetigo. </p>
<p>These results provide robust initial evidence to encourage investigation of ivermectin based mass drug administration as a means to control scabies in highly endemic populations on a larger scale. The trial further strengthens the claim for scabies to be considered as a WHO-listed neglected tropical disease. </p>
<h2>Let’s get rid of scabies</h2>
<p>There are several crucial elements that will lead to successful control of scabies and the alleviation of suffering for those afflicted by the disease. Integration with programs already in place for other neglected tropical diseases (especially those that use ivermectin mass drug administration), recognition and support by WHO, and strong advocacy are essential. </p>
<p>The <a href="http://www.controlscabies.org/">International Alliance for the Control of Scabies</a> was formed in 2012 and is the key global advocacy body for scabies. The Alliance is a network of professionals, including clinicians from high-prevalence areas, public health physicians, policy makers, and researchers, all of whom are committed to the control of human scabies infestation, and to promoting the health and well-being of all those living in affected communities. </p>
<p>Further research into the effect of ivermectin based mass drug administration on the severe bacterial complications of scabies is warranted. </p>
<p>Also, operational research into acceptability and cost effectiveness of mass drug administration will have an impact through strengthening the case for placing scabies alongside other neglected tropical diseases that are targeted for global elimination.</p><img src="https://counter.theconversation.com/content/68147/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Steer receives funding from the National Health and Medical Research Council of Australia and the National Heart Foundation of Australia. </span></em></p>Although a drug of known safety and efficacy is available, scabies still affects more than 100 million people across the world.Andrew Steer, Group Leader, Murdoch Childrens Research Institute. Associate Professor, Department of Paediatrics, University of Melbourne. Paediatric Infectious Diseases Physician, Royal Children's Hospital, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.