School sores (impetigo): online GP treatment, bulk billed

What are school sores?

School sores is the everyday Australian name for impetigo, a common and highly contagious bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes (sometimes both). It mostly affects children aged around 2 to 12, spreading quickly through schools and childcare centres, which is how it earned the name. As the Better Health Channel notes, the infection is usually caused by Staphylococcus bacteria and less commonly by Streptococcus, and it spreads through direct contact with the sores or their fluid.

The bacteria typically enter through a break in the skin: a scratch, graze, insect bite, or a patch of eczema. School sores affect the surface layers of the skin and usually heal without scarring once treated. They are one of several bacterial skin infections a telehealth GP can assess; deeper infections such as boils and cellulitis behave differently and are covered separately.

What do school sores look like?

School sores change appearance as they develop, which is why parents searching for pictures often see quite different rashes. The typical stages are:

• Early stage. Small red spots or tiny fluid-filled blisters appear, most often around the nose and mouth, or on the arms and legs. They are often itchy.
• Blister stage. The blisters enlarge and burst easily, weeping clear or yellowish fluid. Scratching spreads the fluid, and with it the infection, to nearby skin.
• Crusted stage. The weeping areas dry into the classic honey-coloured or golden-brown crusts, as if the sore has been coated in dried honey. Crusts eventually fall off without scarring.

A less common form, bullous impetigo, causes larger blisters that stay intact for longer and tends to appear on the trunk, armpits, groin, or nappy area, more often in infants and younger children.

Rather than comparing your child's rash to photos online, you can show it to a GP: a NewDoc telehealth GP can look at the rash live over video or review a clear photo during the consultation. Sores that cluster only on the lip border, tingle before they appear, and come back in the same spot are more likely cold sores, which are viral and treated differently.

How long off school or childcare? Exclusion and covering sores

Because impetigo spreads so easily between children, Australian health guidance excludes children with school sores from school and childcare until antibiotic treatment is underway. The Royal Children's Hospital Melbourne advises: Keep your child home from childcare or school until 24 hours after starting antibiotics. NSW Health guidance is the same: stay home until at least 24 hours of antibiotic treatment has been given, and cover any sores on exposed skin with a watertight dressing when your child returns.

If you need to stay home to look after your child, a telehealth GP can issue a carer's certificate for your employer during the same consultation, and a school certificate if the school or childcare centre asks for documentation of the absence or of when your child is cleared to return.

When to see a doctor, and when to go straight to an ED

See a GP promptly whenever you suspect school sores. Healthdirect Australia recommends speaking to your doctor if you or your child has symptoms of impetigo, because treatment is important to stop it spreading to other people. Early treatment also clears the sores faster and shortens the time away from school. A bulk billed telehealth consult is usually the fastest way to be seen.

Go to your nearest emergency department, or call 000, if your child:

• Is drowsy, floppy, refusing fluids, or looks seriously unwell
• Has a fever with an area of skin that is rapidly becoming red, hot, swollen, and painful (possible cellulitis or a deeper infection)
• Has signs of dehydration, or pain that seems out of proportion to the rash

Arrange same-day GP review, in person where your GP advises it, if:

• Your child has a fever or is becoming more unwell with the sores
• Your baby is under 12 months old and has widespread sores
• Redness is spreading in the skin beyond the sores themselves
• The sores are not improving, or are still spreading, after 48 to 72 hours of antibiotic treatment

For typical sores in an otherwise well child, telehealth is usually appropriate. The GP will tell you if at any point your child needs to be examined in person.

How a telehealth GP can help with school sores

School sores are well suited to telehealth because the diagnosis is usually made from the look of the rash and the story of how it developed. A NewDoc GP can examine the rash live on video, or review a clear photo you upload, and take a history of how the sores started and spread.

During the consult, your GP can:

• Send an eScript for antibiotic ointment or oral antibiotics directly to your phone, where treatment is clinically appropriate
• Issue a pathology referral for a skin swab if the sores are recurrent, severe, or not responding to treatment
• Issue a carer's certificate for your workplace, or a school certificate for the absence
• Explain exactly how to care for the sores at home, when your child can return to school, and how to protect the rest of the household

For eligible Medicare cardholders, the consultation and all of the above are bulk billed with no out-of-pocket cost. Medicines themselves may be subsidised under the PBS at your pharmacy.

Treatment for school sores: what Australian guidelines recommend

Treatment starts with simple skin care: soak off the crusts with a wet, clean cloth, wash the sores gently with soap and water, pat dry, and cover them. On top of that, the Australian Therapeutic Guidelines (Antibiotic) recommend antibiotic treatment matched to how extensive the infection is:

• A small, localised patch of sores: mupirocin ointment applied to the crusted areas, typically three times a day for 5 days.
• Multiple, larger, or spreading sores: an oral antibiotic, usually flucloxacillin, with cephalexin as the common alternative when flucloxacillin is unsuitable. Doses for children are worked out by weight, which the GP calculates when prescribing.
• Recurrent or atypical infection: a skin swab guides antibiotic choice, and different agents are used where resistant bacteria are found.

Finish the whole course even if the sores look better after a day or two: stopping early can let the infection return. Most sores improve noticeably within 2 to 3 days of starting treatment. Your GP will also look for, and treat, any underlying skin problem that let the bacteria in, such as eczema, scabies, or insect bites, because treating the entry point is part of stopping the cycle.

Recurrent school sores

If school sores keep coming back, the bacteria are usually persisting somewhere. A GP will typically consider:

• An untreated entry point. Broken skin from eczema, scabies, or insect bites gives bacteria a way in; keeping eczema well controlled is often the single most effective prevention step.
• Bacterial carriage. Staphylococcus aureus commonly lives in the nose and can reseed the skin. A decolonisation program of antiseptic body washes plus antibiotic nasal ointment may be prescribed, guided by swab results.
• Household spread. Checking and treating other household members with sores, and hot-washing towels and bedding, breaks the reinfection loop.

A telehealth GP can arrange the swabs, prescribe decolonisation where appropriate, and review progress over follow-up consults, all bulk billed for eligible Medicare cardholders.

Preventing school sores

No measure can guarantee your child will not pick up impetigo, but these steps reduce the risk of catching and spreading it:

• Wash hands regularly with soap, and always after touching sores or dressings.
• Keep fingernails short and clean, and discourage scratching.
• Clean and cover cuts, grazes, and insect bites promptly.
• Treat eczema and scabies properly so the skin barrier stays intact.
• Do not share towels, face washers, clothing, or bedding while anyone has sores.
• Wash linen, towels, and clothes in hot water during an infection.

If sores do appear, early treatment is the best protection for classmates, siblings, and the rest of the household. You can book a bulk billed telehealth appointment the same day and show the GP the rash by video or photo; where the GP decides treatment is appropriate, the eScript and any certificates are sorted in the same consult.