• Clinical science

Staphylococcal scalded skin syndrome (Ritter's disease…)


Staphylococcal scalded skin syndrome (SSSS) is a potentially serious acute skin condition caused by the exfoliative toxins of Staphylococcus aureus and typically affects infants and young children. It is usually preceded by a mucocutaneous staphylococcal infection, such as pharyngitis or bullous impetigo, though this preceding infection may go unnoticed by patients and other caregivers. Following systemic dissemination of toxins from the local infection, SSSS itself typically begins with skin tenderness, erythema, and fever. This is followed a day or two later by flaccid blisters and sloughing off of the superficial layer of skin to reveal moist, red tissue underneath, giving the area a “scalded”-looking appearance. Mucous membranes are spared. A presumptive diagnosis of SSSS is based on clinical findings. Biopsy is only performed in unclear cases and shows separation of the epidermis at the granular layer. Treatment involves the administration of antibiotics and potential intensive care monitoring. The prognosis is generally good, and blisters heal without significant scarring.


  • Rare condition
  • Primarily affects infants and young children; (98% of patients are < 6 years of age)


Epidemiological data refers to the US, unless otherwise specified.


SSSS belongs to the spectrum of diseases mediated by specific staphylococcal toxins, which also includes bullous impetigo, toxic shock syndrome (TSS), and Staphylococcus aureus food poisoning. Unlike TSS, SSSS does not have systemic manifestations (e.g., liver, kidney, bone marrow, and CNS involvement)!


Clinical features


  • Fever, malaise, and irritability
  • Skin tenderness
  • Diffuse or localized erythema, often beginning periorally

After 24–48 hours

Stevens-Johnson syndrome and toxic epidermal necrolysis present with mucosal involvement, SSSS doesn't!



The presumptive diagnosis of SSSS is made based on clinical findings. Cultures (e.g., blood or nasopharynx) are usually taken for confirming the diagnosis, and a biopsy may be performed to exclude suspected differential diagnoses, but is usually not required.


Differential diagnoses

Differential diagnoses of severe exfoliative skin conditions
Age of typical patient
  • Children < 6 years
  • Adults
  • Adults
  • Adverse drug reaction
  • Adverse drug reaction
Clinical features
  • Sloughing of skin, Nikolsky's sign
  • Mucous membrane involvement
  • Typically < 10% of total body surface area
  • Sloughing of skin, Nikolsky's sign
  • ≥ 2 mucous membranes involved
  • > 30% of total body surface area


The differential diagnoses listed here are not exhaustive.


Steroids are contraindicated, as the etiology of SSSS is infectious! (They are, however, indicated in SJS and TEN.)



The complications faced by SSSS patients are similar to those of patients with burns, as both have a compromised skin barrier:

  • Fluid and electrolyte imbalances
  • Thermal dysregulation
  • Secondary infections (e.g., pneumonia, sepsis)


We list the most important complications. The selection is not exhaustive.



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last updated 05/13/2020
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