Streptococcal impetigo manifests itself as appearance of small vesicles that rapidly pustulate and rupture. After the purulent discharge dries, a golden-yellow crust forms. The lesions remain superficial and do not ulcerate or infiltrate the dermis. Pain and scarring do not occur.
The bullous form of impetigo is due to Staphylococcus aureus (phage group II, usually type 71). The initial vesicles turn into fluid bullae that quickly rupture, leaving a moist red surface, which then generates "varnish-like" light brown crusts. Nikolsky sign and scarring do not occur.
The most severe form of S. aureus infection is staphylococcal scalded skin syndrome (SSSS), which is caused by a strain that produces exfoliative exotoxin, producing widespread bullae and exfoliation, with a positive Nikolsky sign (1). It starts abruptly, with fever, skin tenderness, and scarlatiniform rash. Bullae appear over two to three days, and are large and rupture promptly, leaving bright red skin surface.
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