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Pathology of Impetigo

Dr Sampurna Roy MD        


Dermatopathology Case 125 

Diagnosis: Impetigo Contagiosa




Impetigo is a skin infection that is caused by staphylococci (and by streptococci).       

Staphylococcal impetigo frequently affects school children who have a nasal discharge.

Macular and pustular lesions begin around the nose and spread over the face, forming honey-yellow crusts, the hallmark of impetigo.

These crusts are adherent to the surface of the skin, and removal leads to weeping skin lesions.

Staphylococcal and streptococcal impetigo exhibit similar lesions, including folliculitis, pyoderma, wound infection, lymphatic spread and sepsis. 

Staphylococcal impetigo leads to focal tissue necrosis and abscesses more frequently than does streptococcal impetigo.

The rarer variant, bullous impetigo, is characterized by fragile fluid-filled vesicles and flaccid blisters and is invariably caused by pathogenic strains of Staphylococcus aureus.

Bullous impetigo is at the mild end of a spectrum of blistering skin diseases caused by a staphylococcal exfoliative toxin that, at the other extreme, is represented by widespread painful blistering and superficial denudation (the staphylococcal scalded skin syndrome).

In bullous impetigo, the exfoliative toxins are restricted to the area of infection, and bacteria can be cultured from the blister contents.

Microscopic features:


 Images of Dermatopathology Case 125

Impetigo is rarely biopsied as diagnosis is usually established on clinical grounds.

Early lesion is characterized by a subcorneal collection of neutrophils, with exocytosis of these cells through the underlying epidermis.

A few acantholytic cells are sometimes seen.

In established lesions there is a thick surface crust composed of serum, neutrophils and some parakeratotic material.

Gram-positive cocci are found in the surface crust.

In bullous impetigo the subcorneal bulla contains a few acantholytic cells together with neutrophils and some Gram-positive cocci.

Differential diagnosis: 

In staphylococcal 'scalded skin' syndrome the exfoliative toxins are spread hematogenously from a localized source causing widespread epidermal damage at distant sites.

Both occur more commonly in children under 5 years of age and particularly in neonates.

In staphylococcal 'scalded skin' syndrome there is a mild to moderate mixed inflammatory infiltrate in the papillary dermis.

Related posts: Carbuncle ; Furuncle ; Toxic Shock Syndrome ; Staphylococcal Infection ; Streptococcal Infection.

Visit: Staphylococcal impetigo contagiosum by Yutaka Tsutsumi MD


Further reading:

Impetigo presenting as an acute necrotizing swelling of the lower lip in an adult patient.

Bullous impetigo associated with Abiotrophia defectiva in an immunocompetent adult.

Bacterial resistance and impetigo treatment trends: a review.

Interventions for impetigo.

Impetigo update: new challenges in the era of methicillin resistance.

Exfoliative toxins of Staphylococcus aureus.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections.

Impetigo update: new challenges in the era of methicillin resistance.

Topical therapies for impetigo.

Fusidic acid-resistant Staphylococcus aureus in impetigo contagiosa and secondarily infected atopic dermatitis.

Selective immunoglobulin M deficiency presenting with recurrent impetigo: a case report and review of the literature.

Facial and perioral primary impetigo: a clinical study.

Impetigo in soldiers after hand-to-hand combat training.




Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)






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