Skin Infection Antibiotics Online: When Telehealth Can Prescribe

Skin infections are one of the most common reasons Australians visit a GP. Many of these infections - particularly impetigo, infected cuts, folliculitis, and early cellulitis - have presentations that are well-suited to telehealth assessment. A clear photo in good light, a description of how the infection has progressed, and basic information about your medical history give an AHPRA-registered doctor enough to make a confident prescribing decision in many cases.

This article covers the most common bacterial skin infections, what makes each suitable or unsuitable for telehealth, how the photo assessment works, what antibiotic treatments are typically used, and when you need to go to a clinic or emergency department without delay.

Not every skin rash is an infection, and not every infection needs antibiotics. Bacterial infections that commonly warrant antibiotic treatment include the following.

Impetigo

Impetigo is a highly contagious superficial bacterial skin infection caused by Staphylococcus aureus and/or Streptococcus pyogenes. It is common in children but occurs in adults too, particularly in close-contact settings such as households, sporting clubs, and childcare environments.

The classic presentation is honey-coloured crusting, usually around the nose and mouth but can appear anywhere on the body. A less common form (bullous impetigo) produces fragile fluid-filled blisters that rupture to leave a raw, red base.

Impetigo spreads easily through skin-to-skin contact and via shared items like towels. Anyone with an active impetigo infection should avoid close contact with others until at least 24 hours into antibiotic treatment.

Folliculitis

Folliculitis is an infection of the hair follicle, most commonly caused by Staphylococcus aureus. It presents as small red pustules or papules around hair follicles, often on the thighs, buttocks, back, or face.

Mild folliculitis frequently resolves without antibiotics. Regular antiseptic wash (chlorhexidine or povidone-iodine) and keeping the area clean and dry is appropriate management for limited, early cases. More extensive folliculitis, or cases that have not improved after several days of antiseptic care, typically requires oral antibiotics.

Mild to Moderate Cellulitis

Cellulitis is a spreading bacterial infection of the deeper skin and subcutaneous tissue. Unlike impetigo, which is superficial, cellulitis penetrates into the dermis and sometimes deeper. The typical presentation is a spreading area of redness, warmth, and swelling with poorly defined borders. The skin surface usually remains intact (no crusting, no blisters, no open wound), which distinguishes it from some other infection types.

Cellulitis is most common on the lower legs but can occur anywhere. Mild to moderate cellulitis without systemic symptoms - no fever, no rigors, no rapid spread - is appropriate for telehealth management with oral antibiotics. Systemic involvement changes this entirely.

Infected Cuts and Wounds

Minor lacerations, abrasions, and puncture wounds can become infected, particularly if initial wound care was inadequate or if the wound was contaminated. Signs of wound infection include increasing redness around the wound edges, warmth, swelling, purulent (pus) discharge, and pain that increases after the first 24-48 hours rather than improving.

Many infected wounds can be assessed via telehealth with a clear photo showing the wound and the surrounding skin, along with a description of how long ago the injury occurred and how the appearance has changed.

Infected Insect Bites

Insect bites can introduce bacteria through the skin break caused by scratching. Infected bites typically show expanding redness and warmth around the bite site, sometimes with a central pustule. The difficulty is distinguishing a straightforward local allergic reaction (which does not need antibiotics) from a bacterial infection (which does). Spreading redness beyond 2-3cm from the bite site, increasing rather than decreasing pain, and the presence of pus suggest infection over simple allergy.

Infected Eczema (Eczema Herpeticum Excluded)

People with eczema have a compromised skin barrier that makes them significantly more susceptible to bacterial colonisation and infection. Staphylococcus aureus is the primary pathogen in infected eczema. Signs of superimposed bacterial infection include sudden worsening of eczema, yellow crusting, weeping areas, and increased redness beyond the usual rash distribution. Cefalexin is typically first-line treatment.

Note: eczema can also be secondarily infected with herpes simplex virus (eczema herpeticum), which is a medical emergency requiring urgent in-person assessment. Eczema herpeticum presents with sudden worsening, punched-out erosions or vesicles across the rash area, and often fever. It does not respond to antibiotics.

Skin infections have a significant visual component, which makes them more amenable to telehealth assessment than many other conditions. An online doctor assessing a skin infection draws on two information sources: what you tell them and what the photos show.

**Symptom history:** When did you first notice it? Has it spread since, and if so how quickly? Is there pain, warmth, or itching? Any fever or chills? Have you had similar infections before? Did you recently have a skin injury, insect bite, or contact with someone with a known skin infection?

**Spread pattern:** The rate and direction of spread is clinically significant. A localised patch of impetigo that has not grown in size over 24 hours is a different clinical picture from cellulitis that has visibly expanded over the same period. This information cannot be obtained from a photograph alone - the patient must describe the progression.

**Systemic symptoms:** Fever, rigors (shaking chills), swollen lymph nodes, feeling genuinely unwell. Any systemic symptom substantially changes the clinical risk profile and usually indicates the infection has progressed beyond what telehealth should manage.

**Photos:** Clear images showing the full extent of the redness, the character of the lesion surface (crusting, blistering, open wound, intact skin), and any visible pus or discharge.

Impetigo is one of the better-suited skin infections for telehealth prescribing. The clinical picture is usually distinctive - the honey-coloured crusting is recognisable in a good photograph - and the treatment is well-established.

**First-line treatment for localised impetigo:** Topical mupirocin 2% cream or ointment, applied three times daily for 5 days. Mupirocin is effective and minimises systemic antibiotic exposure. It is appropriate when lesions are few and limited to a small, easily accessible area.

**First-line treatment for widespread or spreading impetigo:** Cefalexin 500mg four times daily for 5-7 days. Cefalexin is a first-generation cephalosporin with excellent activity against both Staph aureus and Strep pyogenes. It is the most commonly prescribed oral agent for impetigo in Australian clinical practice.

**Alternative for penicillin/cephalosporin allergy:** Trimethoprim/sulfamethoxazole (cotrimoxazole) covers the likely organisms and is used when cefalexin cannot be given due to allergy.

Impetigo is highly contagious until at least 24 hours after starting antibiotics. Children should not attend school or childcare during this period. Shared items (towels, sporting equipment, clothing) should not be shared with others.

**Children under 2 with impetigo should be seen in person.** Clinical assessment of young children requires a physical examination to confirm the diagnosis and check for complications.

Cellulitis presents on a wide spectrum from genuinely mild to life-threatening. The telehealth assessment must identify where on that spectrum a given presentation sits.

**Appropriate for telehealth prescribing:** Mild cellulitis with a well-defined border, no fever (temperature below 38.0C), no systemic symptoms, no rapid spread. The patient should be able to draw a skin marker line around the edge of the redness and photograph it so the doctor can see the starting point.

**Useful patient instruction:** Draw around the border of the redness with a skin-safe marker or biro. Photograph the area next to the line. Check the redness against the line every 4-6 hours. If redness is spreading beyond the drawn border within 24-48 hours despite starting antibiotics, attend a clinic or emergency department - do not wait for your next telehealth review.

**Requires in-person assessment:** Any cellulitis with fever, rigors, or feeling systemically unwell. Cellulitis that is expanding visibly within hours. Cellulitis of the face, particularly around the eye. Lower leg cellulitis in a patient with diabetes, peripheral arterial disease, or immunosuppression. Cellulitis following an animal bite. Any case where the diagnosis is uncertain (could this be a deep vein thrombosis? Could this be necrotising fasciitis?).

**First-line antibiotic for mild cellulitis:** Cefalexin 500mg four times daily for 5-7 days, extending to 10 days for slower-responding cases. The Therapeutic Guidelines (eTG) Antibiotic guidelines recommend cefalexin as first-line for non-purulent cellulitis managed in the community.

Intravenous antibiotics are required for cellulitis with systemic involvement. IV flucloxacillin or cefazolin are standard hospital treatments. Telehealth cannot arrange IV antibiotics - a patient who needs IV therapy needs to present to an emergency department or short-stay unit.

Photo quality significantly affects what the doctor can assess. The difference between a useful clinical photo and an unhelpful one often comes down to a few straightforward factors.

**Light:** Natural light is best. Avoid using the phone flash directly on the skin - it causes glare that obscures surface detail. Photograph near a window with indirect daylight, or use a lamp positioned to the side rather than directly above.

**Scale reference:** Place a coin (a 20-cent piece works well), a ruler, or a credit card next to the affected area in at least one photo. This allows the doctor to estimate the size of the infection accurately.

**Capture the borders:** For any spreading infection - cellulitis, spreading impetigo - make sure the photo captures the full extent of the redness including the edge where normal and infected skin meet. This border is one of the most clinically informative features.

**Multiple angles:** A front-on photo showing the lesion clearly, and a wider shot showing the surrounding skin context. For a lower leg cellulitis, include a photo that shows the knee and ankle so the doctor can see what proportion of the limb is involved.

**Clean the area first:** Gently clean the area before photographing (remove dried exudate if present) so the underlying skin surface is visible. Do not cover with dressings before photographing.

**Show the drawn border:** If the doctor has asked you to draw a border around the redness to monitor spread, photograph the drawn border clearly and send a comparison photo at each check-in.

Most skin infections in Australia are caused by strains of Staph aureus that are sensitive to cefalexin. However, community-acquired MRSA (methicillin-resistant Staphylococcus aureus) is increasingly recognised in Australia, particularly in some regional and remote communities and in people with recent healthcare exposure.

MRSA is resistant to cefalexin and flucloxacillin. It is NOT effectively treated by doxycycline in most skin infection contexts.

If you have a skin infection that is not improving after 48-72 hours on cefalexin, or if you have had MRSA infections before, this needs to be communicated clearly to the doctor. Trimethoprim/sulfamethoxazole is often effective against community-acquired MRSA strains and may be the appropriate choice in these situations. The prescribing decision changes significantly once MRSA is suspected.

The most commonly prescribed oral antibiotics for bacterial skin infections in Australia:

| Infection type | First-line agent | Typical dose and duration | |---|---|---| | Impetigo (widespread) | Cefalexin | 500mg four times daily, 5-7 days | | Impetigo (very localised) | Topical mupirocin | Applied three times daily, 5 days | | Mild cellulitis | Cefalexin | 500mg four times daily, 5-7 days | | Infected wound | Cefalexin | 500mg four times daily, 5-7 days | | Infected eczema | Cefalexin | 500mg four times daily, 5-7 days | | Suspected MRSA | Trimethoprim/sulfamethoxazole | Per doctor recommendation |

Cefalexin is taken with or without food, but consistency matters more than timing relative to meals. Complete the full course even if the infection looks significantly better before you finish - stopping early is one of the most common causes of recurrence.

Common side effects of cefalexin include mild gastrointestinal upset and diarrhoea. Taking it with food reduces this. If you develop a rash, hives, or breathing difficulty, stop the medication and seek immediate medical attention - this may indicate an allergic reaction.

**Note on PBS pricing:** Cefalexin and trimethoprim/sulfamethoxazole are PBS-listed antibiotics. With a Medicare card, general patients pay up to $31.60 per item; concession card holders pay up to $7.70 (Services Australia PBS co-payment thresholds, 2025-26).

Some skin infection presentations cannot and should not be managed via telehealth. Recognising these situations matters because delay in these cases carries real risk.

**Periorbital or orbital cellulitis (infection around or behind the eye):** Any spreading infection involving the eyelids, particularly with proptosis (eye appearing pushed forward), restricted eye movement, or vision change, must be assessed urgently in person. Infection can spread from the periorbital tissues into the orbit and from there to the brain. This is a medical emergency. Do not wait.

**Facial cellulitis:** Facial skin has a rich blood supply and lymphatic drainage that connects to the cavernous sinus. Facial cellulitis, particularly around the central face (nose, upper lip, cheek), carries a risk of intracranial spread that makes in-person assessment mandatory.

**Any skin infection in a child under 2:** Young infants and toddlers can deteriorate rapidly. Bacterial skin infections in this age group require physical examination, weight-based dosing assessment, and in some cases paediatric review. Do not attempt to manage skin infections in this age group via telehealth.

**Infection following an animal bite (particularly cats or dogs):** Animal bite wounds have a distinct bacteriology (including Pasteurella multocida from cat bites) that changes the antibiotic selection and often requires wound assessment that includes cleaning, exploration for depth, and assessment of underlying structures. These need in-person care.

**Signs of necrotising fasciitis or deep infection:** This is covered below under red flags.

Necrotising fasciitis deserves particular mention. It is rare but rapidly fatal without surgical treatment. The LRINEC (Lab Risk Indicator for Necrotising Fasciitis) score used in hospital settings combines blood test results with clinical findings - neither of which can be assessed via telehealth. The clinical red flags visible without blood tests are: pain dramatically out of proportion to appearance, skin discolouration (grey, purple, or dark mottling), skin that appears shiny and tight, crepitus (crackling feeling under the skin), and systemic toxicity. Any combination of these in the context of a skin infection is an emergency.

If your presentation is appropriate for telehealth assessment, the process through InstantMed works as follows:

1. Select "GP Consultation" and describe your skin infection, including the type of infection, when it started, how it has progressed, any fever or systemic symptoms, and your allergy history. 2. Upload clear photos of the affected area following the guidance above: natural light, scale reference (coin or ruler), the full extent of the redness, and any visible wound or lesion. 3. An AHPRA-registered doctor reviews your case. Consultations are available 8am to 10pm AEST, seven days a week, with a target review time of 1-2 hours. 4. If antibiotics are clinically appropriate, an eScript is issued and delivered to your phone via SMS as a digital token. 5. Take the SMS to any Australian pharmacy to fill the prescription immediately. PBS pricing applies with a Medicare card.

If the doctor determines that in-person assessment is needed, you will receive clear guidance on what to do next. A recommendation to seek in-person care is the correct clinical outcome for presentations that fall outside safe telehealth management - it is not a service limitation.

If you have questions about whether your specific presentation is appropriate for a telehealth assessment, a general consultation is a reasonable starting point. The doctor will advise you from there.