Updated: 9/20/2018

Staphylococcal Scalded Skin Syndrome (SSSS)

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  • 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.
  • 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
  • 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)
  • 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
  • Toxic epidermal necrolysis
    • full thickness epidermal cell necrosis and supepidermal cleavage
  • Bullous impetigo
    • honey-crusted erosions
    • more widespread
    • positive superficial wound cultures
  • 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)
  • Secondary infection of denuded skin
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