Snapshot A 3-year-old girl presents to her pediatrician with a widespread rash. She recently had fevers and a sore throat. She has perioral fissues and a desquamating rash in the groin and neck. When light pressure is applied, the skin easily sloughs off. Superficial wound cultures and bacterial cultures are negative. Introduction Clinical definition exfoliative skin infection caused by Staphylococcus aureus toxins Epidemiology incidence 9-25 per 100,000 children demographics affects neonates and children Pathophysiology mechanism of injury systemic spread of Staphylococcus aureus toxins exfoliative exotoxins A (ETA) or B (ETB) both are trypsin-like serine proteases that digest desmoglein-1, a cadherin that mediates keratinocyte adhesion in the epidermis loss of cell-cell adhesion in stratum granulosum leads to bullae and sloughing Associated Staphylococcus aureus conditions children preceding respiratory tract infection preceding conjunctivitis preceding otitis media Prognosis survival with treatment very good Presentation Symptoms primary symptoms prodrome with irritability, malaise, fever, and sore throat Physical exam erythematous tender patches progressing to painful desquamation and superficial skin sloughing with “scalded” appearance generalized and flaccid bullae perioral and periorbital fissures mucous membranes not involved positive Nikolsky sign which describes a separation of epidermis from dermis with slight pressure distribution is often in the face, neck, groin, axillae, and other flexural surfaces mucosal surfaces not involved (vs. SJS & TEN) Studies Labs blood cultures typically negative superficial wound cultures and bullae fluid cultures are sterile Biopsy indications if diagnosis of toxic epidermal necrolysis needs to be ruled out Histology intraepidermal cleavage Differential Toxic epidermal necrolysis full thickness epidermal cell necrosis and supepidermal cleavage Bullous impetigo honey-crusted erosions more widespread positive superficial wound cultures Treatment Medical intravenous anti-staphylococcal antibiotics indications administered in the treatment of staphlococcal scalded skin syndrome modalities nafcillin or oxacillin in methicillin-sesitive Staphylococcus aureus (MSSA) vancomycin in cases of methicillin-resistant Staphylococcus aureus (MRSA) Complications Secondary infection of denuded skin