Staphylococcal scalded skin syndrome
Staphylococcal scalded skin syndrome is a toxin-mediated illness, usually in neonates or young children, caused by exfoliative toxin-producing Staphylococcus aureus that cleaves the epidermis at the granular layer, producing fever, marked skin tenderness, fragile bullae, and sheet-like desquamation with a positive Nikolsky sign but sparing the mucous membranes. Diagnosis is clinical; treatment is prompt intravenous penicillinase-resistant penicillin (or an alternative such as cefazolin, with vancomycin or clindamycin reserved for suspected MRSA or severe disease) plus meticulous supportive skin and fluid care.
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What this article covers
- Overview
Definition: staphylococcal scalded skin syndrome (SSSS) is a toxin-mediated illness caused by infection with phage group II Staphylococcus aureus, which produces exfoliative toxins A and B.
- Epidemiology
Predominantly a disease of neonates and young children: SSSS classically affects children under 6 years old.
- Risk factors
Young age: neonates and infants are at particular risk because of immature renal toxin clearance and reduced ability to neutralize circulating exfoliative toxin.
- Pathophysiology
Toxin production: phage group II Staphylococcus aureus produces exfoliative toxins A and B, which circulate systemically from a primary infected or colonized focus.
- Clinical features
Diagnostic pattern: fever, marked skin tenderness, rapidly spreading erythema, fragile superficial blisters, and sheet-like peeling with gentle pressure.
- Differential diagnosis
Stevens-Johnson syndrome/toxic epidermal necrolysis: shows mucosal erosion at 2 or more sites and full-thickness epidermal necrosis on biopsy, unlike the mucosa-sparing, high intraepidermal split of SSSS.
- Diagnosis
Diagnostic basis: SSSS is a clinical diagnosis in a neonate or young child with fever, marked skin tenderness, rapidly spreading erythema, fragile bullae, sheet-like peeling with gentle pressure, and little or no mucosal erosion.
- Management
First step: hospitalize the patient with generalized disease and begin empiric intravenous antibiotic treatment targeting Staphylococcus aureus while cultures from the primary focus are pending.
- Complications
Dehydration and electrolyte disturbance: loss of the epidermal barrier over large body surface areas leads to significant fluid and electrolyte losses.
- Prognosis
Favorable in children: children usually re-epithelialize within about 1 to 2 weeks without scarring when treatment is prompt.
- Prevention
Identify and treat the primary staphylococcal focus: searching for and treating the source of infection (a wound, abscess, or colonized site such as the nose or umbilicus) reduces ongoing toxin production and the risk of spread.
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