Pharmacy First

The Pharmacy First service is for non-bullous impetigo in adults and children aged one year and over. It is important for pharmacy teams to be able to advise customers that the service excludes bullous impetigo, recurrent impetigo (defined as two or more episodes in the same year), and pregnant individuals under 16 years of age.

The patient pathway through the Pharmacy First impetigo service will start with the pharmacist confirming the diagnosis of impetigo through a visual examination.

They will also consider the risk of deterioration or serious illness, whether the patient is immunosuppressed and infection is widespread, and if any severe complications are suspected (such as deeper soft tissue infection).

If any of these are seen, the pharmacist will consider calculating the National Early Warning Score 2 (NEWS2) ahead of signposting the person to A&E or calling 999 if they deem it a life-threatening emergency. NEWS2 measures six physiological parameters to alert healthcare providers to the potential deterioration of adult patients.

If the pharmacist doesn’t see anything to suggest risk of deterioration or serious illness, they will next determine if the patient follows the typical progression of impetigo clinical features. These include having a thin-walled lesion which ruptures easily, and dried golden-yellow or yellow-brown crusts.

If the patient is not displaying these clinical features, impetigo is less likely, so the pharmacist will consider an alternative diagnosis – such as eczema or shingles – and proceed appropriately with solutions for these conditions.

If these clinical features are present and the pharmacist considers that impetigo is more likely, this is the gateway point for the Pharmacy First impetigo service, and their next step is to check the number of lesions/clusters present.

If the patient has three or fewer lesions/clusters present, this indicates localised non-bullous impetigo and the pharmacist will offer hydrogen peroxide 1% cream for five days (subject to inclusion/exclusion criteria in the PGD) plus self care, or if unsuitable or ineffective will offer fusidic acid cream for five days (subject to inclusion/exclusion criteria) plus self care.

If the patient has four or more lesions/clusters, this indicates widespread

non-bullous impetigo and the pharmacist will offer flucloxacillin (if no allergy) for five days (subject to inclusion/exclusion criteria) plus self care – unless the person has a reported penicillin allergy (in which case they will be offered clarithromycin for five days, subject to inclusion/exclusion criteria, plus self care), or has a penicillin allergy and is pregnant (when they will be offered erythromycin for five days, subject to inclusion/exclusion criteria, plus self care).

For all gateway patients, if their symptoms worsen rapidly or significantly at any time, OR do not improve after completion of the treatment course, the pharmacist will make an onward referral to their GP or other provider, as appropriate.

In addition, for all patients, whether they meet the gateway or not, the pharmacist will share self care and safety-netting advice using the British Association of Dermatologists Impetigo leaflet.