How to manage bacterial skin infections

Primary care patients commonly present with bacterial skin infections. These can range from mild and localised manifestations to rapidly progressive, potentially serious conditions.

However, effective management of bacterial skin infections is possible in a primary care setting, especially with training in general dermatology. The management relies on accurate clinical assessment, appropriate antimicrobial use, and timely recognition of complications.

Common presentations of bacterial skin infections

GPs commonly encounter the following bacterial skin infections:

• Impetigo,
• Cellulitis,
• Erysipelas, and
• Folliculitis

The most frequent causative organisms are Staphylococcus aureus and Streptococcus pyogenes.

Diagnosis

A thorough history and examination are essential for correct diagnosis. Key features to assess include onset, progression, associated systemic symptoms such as fever and malaise, and comorbidities such as diabetes. Potential portals of entry, such as wounds, insect bites, or dermatological conditions, also need to be identified and assessed.

Initial assessment and risk stratification

Patients should be stratified based on severity:

• Mild infections: Localised, no systemic signs.
• Moderate infections: Spreading erythema, mild systemic symptoms.
• Severe infections: Rapid progression, systemic toxicity, immunocompromised status, or suspicion of necrotizing infection.

There are certain red flags requiring urgent referral. These include:

• Disproportionate pain,
• Skin necrosis,
• Bullae,
• Crepitus, or
• Signs of sepsis

Management strategies

The management strategy depends on the type and severity of the infection. Here’s an overview:

Localised infections

For mild infections, such as limited impetigo or folliculitis, GPs should emphasise hygiene measures, including washing and avoiding sharing personal items.

Topical antibiotics, such as mupirocin or fusidic acid, are first-line for localised impetigo.

Incision and drainage are the primary treatment options for small abscesses; antibiotics may not be necessary unless there is surrounding cellulitis or systemic involvement.

Systemic antibiotic therapy

Oral antibiotics are indicated for:

• Extensive impetigo
• Cellulitis and erysipelas
• Infections with systemic features

• Non-purulent infections: beta-lactams (e.g. flucloxacillin)
• Penicillin allergy: macrolides or clindamycin may be used
• Suspected MRSA: Consider local resistance patterns

Duration typically ranges from five to seven days, but may be extended depending on clinical response.

Special considerations

Patients with underlying conditions such as diabetes, peripheral vascular disease, or immunosuppression require closer monitoring due to a higher risk of complications and treatment failure.

Recurrent infections require evaluation for predisposing factors, including:

• Skin barrier disruption,
• Chronic oedema, or
• Colonisation with pathogenic bacteria

When to refer

Referral to secondary care is warranted when:

• There is suspicion of deep or necrotizing infection
• The patient shows no improvement after 48 to 72 hours of appropriate therapy
• There are significant comorbidities or immunosuppression
• Intravenous antibiotics are required

Management of bacterial skin infections in primary care requires a structured approach. This includes good clinical judgment, appropriate antimicrobial therapy, and vigilance for complications. Early recognition and intervention can prevent progression and reduce the need for hospital-based care. On the other hand, responsible prescribing minimises antimicrobial resistance and supports long-term public health goals.

- Dr Rosmy De Barros

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References

1. Linz, M. S., Mattappallil, A., Finkel, D., & Parker, D. (2023). Clinical Impact of Staphylococcus aureus Skin and Soft Tissue Infections. Antibiotics (Basel, Switzerland), 12(3), 557. https://doi.org/10.3390/antibiotics12030557
2. Efstratiou A, Lamagni T. Epidemiology of Streptococcus pyogenes. 2022 Oct 30 [Updated 2022 Nov 7]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes: Basic Biology to Clinical Manifestations [Internet]. 2nd edition. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2022 Oct 8. Chapter 19. Available from: https://www.ncbi.nlm.nih.gov/books/NBK587100/
3. Ling, J. Y., How, C. H., Chien, J. M. F., Poulose, V., & Ng, M. C. W. (2025). Skin and soft tissue infections in primary care. Singapore medical journal, 66(2), 108–113. https://doi.org/10.4103/singaporemedj.SMJ-2022-151
4. Xie, J., Li, M., Yang, S., & Dong, Q. (2025). Topical administration of mupirocin ointment and fusidic acid in bacterial infection-induced skin diseases. Postepy dermatologii i alergologii, 42(1), 42–46. https://doi.org/10.5114/ada.2024.145185
5. Bouza, E., & Burillo, A. (2022). Current international and national guidelines for managing skin and soft tissue infections. Current opinion in infectious diseases, 35(2), 61–71. https://doi.org/10.1097/QCO.0000000000000814
6. Yachmaneni, A., Jr, Jajoo, S., Mahakalkar, C., Kshirsagar, S., & Dhole, S. (2023). A Comprehensive Review of the Vascular Consequences of Diabetes in the Lower Extremities: Current Approaches to Management and Evaluation of Clinical Outcomes. Cureus, 15(10), e47525. https://doi.org/10.7759/cureus.47525