Staphylococcal Scalded Skin Syndrome

Staphylococcal scalded skin syndrome develops in patients with clinically inapparent staph infections caused by an exotoxin produced by Staphylococcus aureus. It occurs primarily in infants and young children, and also in immunosuppressed adults or those with renal insufficiency. The exotoxins involved, collectively known as exfoliatin, are elaborated by the bacteria, released into the circulation, and cause acantholysis and intraepidermal cleavage of the skin. 14

An episode of SSSS frequently begins as a clinically inapparent staphylococcal infection of the conjunctiva, nasopharynx, or umbilicus. The disease course can be divided into three phases: initial/erythroderma; exfoliative; and desquamation/recovery. Initially, the patient (or parent) notes the sudden appearance of a tender erythroderma, usually diffuse, although localized disease has been described. The involved skin may have a sandpaper texture. Tender erythema is prominent in the perioral, periorbital, and groin regions, as well as in the skin creases of the neck, axilla, popliteal, and antecubital areas. The mucous membranes are spared. The exfoliative stage begins on the second day of the illness. The erythematous skin wrinkles and peels off at sites of minor trauma or with minimal lateral pressure with the examiner's fingertip, illustrating the positive Nikolsky's sign (also found in TEN). Large, flaccid, fluid-filled bullae and vesicles then appear. These lesions easily rupture and are shed in large sheets; the underlying tissue resembles scalded skin and rapidly desiccates. After 3 to 5 days of illness, the involved skin desquamates, leaving normal skin in 7 to 10 days. The differential diagnosis for SSSS includes toxic epidermal necrolysis, TSS, exfoliative drug eruptions, and localized bullous impetigo.

Management includes fluid resuscitation and correction of electrolyte abnormalities, as well as identification and treatment of the source of the toxigenic staphylococcus with oxacillin or vancomycin. Corticosteroids are not recommended.

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