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Staphylococcal scalded skin syndrome

Last updated: January 3, 2021

Summary

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.

Epidemiology

  • Rare condition (∼ 8 per 1,000,000 children) [1]
  • Primarily affects infants and young children between 6 months and 5 years of age (peak incidence: 2–3 years) [2]
  • Rare in adults: may occur in adults with predisposing conditions (e.g., impaired renal function or immunosuppression) [3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

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 (involvement of, e.g., liver, kidney, bone marrow, CNS).

Clinical features

Initially [5]

After 24–48 hours [5]

Stevens-Johnson syndrome and toxic epidermal necrolysis manifest with mucosal involvement, SSSS does not.

Diagnostics

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
SSSS Stevens-Johnson syndrome (SJS) Toxic epidermal necrolysis (TEN)
Age of typical patient
  • Children < 6 years
  • Adults
  • Adults
Etiology
  • Adverse drug reaction
  • Adverse drug reaction
Clinical features
Biopsy

The differential diagnoses listed here are not exhaustive.

Treatment

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

Complications

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.

Prognosis

References

  1. Staiman A, Hsu DY, Silverberg JI. Epidemiology of staphylococcal scalded skin syndrome in U.S. children.. Br J Dermatol. 2018; 178 (3): p.704-708. doi: 10.1111/bjd.16097 . | Open in Read by QxMD
  2. Davidson J, Polly S, Hayes PJ, Fisher KR, Talati AJ, Patel T. Recurrent Staphylococcal Scalded Skin Syndrome in an Extremely Low-Birth-Weight Neonate.. AJP reports. 2017; 7 (2): p.e134-e137. doi: 10.1055/s-0037-1603971 . | Open in Read by QxMD
  3. Handler MZ, Schwartz RA. Staphylococcal scalded skin syndrome: diagnosis and management in children and adults.. J Eur Acad Dermatol Venereol. 2014; 28 (11): p.1418-23. doi: 10.1111/jdv.12541 . | Open in Read by QxMD
  4. Yamasaki O, Yamaguchi T, Sugai M. Clinical Manifestations of Staphylococcal Scalded-Skin Syndrome Depend on Serotypes of Exfoliative Toxins. J Clin Microbiol. 2005; 43 (4): p.1890-1893. doi: 10.1128/JCM.43.4.1890-1893.2005 . | Open in Read by QxMD
  5. Garfunkel LC, Kaczorowski J, Christy C. Pediatric Clinical Advisor E-Book: Instant Diagnosis and Treatment. Elsevier Health Sciences ; 2007
  6. Ladhani S, Robbie S, Garratt RC, Chapple DS, Joannou CL, Evans RW. Development and Evaluation of Detection Systems for Staphylococcal Exfoliative Toxin A Responsible for Scalded-Skin Syndrome. J Clin Microbiol. 2001; 39 (6): p.2050-2054. doi: 10.1128/JCM.39.6.2050-2054.2001 . | Open in Read by QxMD
  7. Patel GK, Finlay AY. Staphylococcal scalded skin syndrome: diagnosis and management.. Am J Clin Dermatol. 2003; 4 (3): p.165-175.